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Dec. 30, 2019 10: 14AM No, 0315 K 1 <br /> 1� ,�,� A �v Environmental Health DerIrriet't.j <br /> y , <br /> r-,ouNr :.... , DEC ; 0Z019 <br /> 'i: r+.s�,. �s:,?t'•�r,C53 4�'t'G'W� �1S?r'ft, <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corectsd within 30 days of <br /> receipt of this Inspection. This certitication form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1,2(c)(1) <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 resultslmanifests/training records/other appropriate paperwork,andlor photos verifying corrections <br /> Operators certification <br /> Inspection Date: November 26, 2619 Inspected By: JASON GAITAN <br /> Facility Address; 1163 VANDERBILT CIR, MANTECA DERS ID: 10181245 <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. i 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 Statement <br /> 3, 1 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 and/or <br /> imprisonment for known violations, (1-18C <br /> FH SC 25191) <br /> Name: ( b 1PVav-oqejl <br /> Signature: > ate: la ,j q,j q <br />