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SAN J U A Q U I N Environmental Health Department <br /> C(DUNTY-- <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 of <br /> receipt of this inspection. This certification 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(I R)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,andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: September 17, 2019 Inspected By: JASON GAITAN <br /> Facility Address: 12608 S HARLAN RD, LATHROP CERS ID: 10185053 <br /> 1 certify under penalty of law that: <br /> 1. I 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 Statement <br /> 3. 3 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. (HSG 25191) <br /> Name: Title: -e— <br /> Signature: Date: l <br />