Laserfiche WebLink
S A N J Q A Q U I N Environmental Health Department <br /> t_ 00tgTY <br /> RED� <br /> RETURN TO COMPLIANCE CERTIFICATION JAN 70N 'ww� <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> -gEALTI'I <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Departe!"VFRQX�'4t�GlrE + <br /> the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404 . 1 . 2 (c) ( 1 ) DEPARTMENT <br /> All corrections to other violations noted in the attached Inspection Report ( IR) or Continuation Form , or disputes to any <br /> violations , are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report, HSC 25185 (c) (3) <br /> Note : All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate . <br /> For this certification to be complete , the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator' s certification <br /> Inspection Date : October 03 , 2019 Inspected By : CHRISTINE LAWRENCE <br /> Facility Address : 17830 S IDEAL PKWY , MANTECA CERS ID : <br /> I certify under penalty of law that: <br /> 1 , 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2 . 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate , and complete: <br /> Photos ✓ Paperwork Z Statement <br /> 39 l am authorized to submit this certification on behalf of the Respondent. <br /> 4 . 1 am aware that there are significant penalties for submitting false information , including the possibility of a fine <br /> and/or imprisonment for known violations. ( HSC 25191 ) <br /> Name : tea-- 0 v.ktNA ►'� Title : ,tea. <br /> Signature : o-- oi -hv ACa �n Date : " kV tq <br />