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r <br />t <br />QUI <br />SA.N...JOA <br />:�+ �` vim.}•�.•{�� �- � .� L�N <br />r. <br />AW, e- at M... -e S. S <br />Environmental Health Depart ent <br />RETURN TO COMPLIANCE CERTIFICATION <br />any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days �f <br />eceipt of this inspection. This certification form must be submitted to the Environmental Health Depaftmen <br />he bottom of this form within ��30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />tt <br />Y <br />EHE address <br />All corrections to other violations noted in the a�#ached inspection Report (IR) or Continuation Form,vrolatians, ire fo be Submi�teC# using #hoc r�r+if��-n+i.,�, ��,4,..,�.,...,...��_r,��,_.._ yr disputes to any <br />- --- -,� -...•• •,•v■ ����r�r.�«Vi s Gll i41 kCLUf i Intl 1i3 �'1"'li ) USIITYlIi"'! "�f 1 r+tA►.e+ <br />Inspection Report. HSC 25185(c){3} <br />- ---• • -� � �_ �.. ..... ■.iii Fir � vV LiGi �7 <br />Note,* All EHD staff bane associated with fa <br />billed at the current hourly rate. <br />Fnr Chic r-Prf0f1f%!3f1n +„ h„ <br />unless otherwise specified in the <br />fling to comply by the above noted dates will be <br />—• ...,.. ..v. a�� �vu��vi � �V uU L,V,,,Nrtj Le , the operator of the site must inr.1Hr1Pd1 <br />A statement documenting v�hatc or��ct�ve actions were taken or will be talon for each violation <br />Copies of sample resultsimanifes sltrainin� reca�-dsla�h�� appropria#e papen�v�rk andla�photos Opera#or's certification Iverifying corrections <br />Inspection Date: <br />November 26, 2019 <br />Facility Address: 1140 BESSEMER AVE STE 31 Manteca <br />certify under penalty of law that.- <br />Inspected By: JASON GAITAN <br />CERS ID : 10 1$ 3107 <br />have <br />corrected the violations specified in the Inspection Report from the above-mentioned ins ect�o� dapte. <br />2. f 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. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for <br />imprisonment for known violations. (HSC 25191) <br />T <br />Name: 4Z.,eel, 2JO <br />Signatu <br />submitting false information, including the POSSibility of a fine and/or <br />Title: �AIIIIIII -aelgeT10"I'%eY 71c,/oily <br />Date: <br />