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MENDE <br /> San Joaquin County <br /> REG - Ot <br /> ?V7 Environmental Health Department fttk <br /> J 1868 East Hazelton Avenue, Stockton,California 95205-6232 <br /> Tot1phane, (209)468-3420 Pax:(209)458-3433 Web: hrl <br /> EN\j1VA0NMEWTP,L HEALM <br /> r)t:. TMENT RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINM violations noted in the'Notice to Comply"in the attached Inspection Report must be gqZg_cAg.�.within 30,LM of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHO)a ldress <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(0)(1) <br /> All 11-OdOn2 LQQtb.QLYj9WVQnnoted in the attached Inspection Report(IR)or Continuation Form,or disputes to an f <br /> violations, are to be submitted using this certification and returned to EHI)yibla 3D_daXrj unless otherwise speccifiedi the <br /> inspection Report. HSC 25186(c)(3) <br /> Note: All END staff time associated with failing to comply by the above noted dates will b <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 <br /> corrections <br /> Inspection Date: December 04, 2017 Inspected By, JOHN ALANIZ <br /> Facility Address: 1151W LOUISE AVE, MANTECA CERS ID: 10180661 <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 SACH VIOU TION <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 <br /> and/or imprisonment for known violations. (HSC 26191) <br /> Name: 41X.R1 kfq&A 4_L_ -Title: 16 <br /> Signature; Date: /.1- /7 <br /> L0001Z0000 NOUAM i=m dus allo 6%M960Z XVd RdTZ:ZT LTOZ/VT/ZT <br />