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56b5 ' ° N Wa95 ll 6lOZ ll ' daS avail paniaaa � <br /> SA I!JDANI N Environmental Health Department <br /> c <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be <br /> receipt of this inspection . This certificatlon form must be submitted to the Environmental Health Department ( EHD ) address <br /> correcf <br /> at the ;bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404 . 1 . 2 (c) (1 ) <br /> All corrections tother viol to noted in the attached Inspection Report ( IR) or Continuation Form , or disputes to an <br /> violation 's , are to be submitted using this certification and returned to EHE) ith . 3 da <br /> Inspection Report , HSC 25185 (c)(3 ) unless otherwise specified in the <br /> Nate : All EHD staff time associated with failing to comply by the above noted dat <br /> billed at the current hourly rate, es will be <br /> For this certification to be complete , the operator of the site must incl <br /> uder <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> I IFCopies of sample results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification Y� g tons <br /> Inspec11 tionDate , _ August 19 , 2019 <br /> Inspected By : PAUL NSO <br /> Facility Address : 1229 E LOUISE AVE , MANTECA <br /> CERS ID : 10186837 <br /> Foerfify r penalty of law that: <br /> e corrected the violations specified in the Inspection Report from the above-mentioned inspection date , <br /> ?. . . 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATIO <br /> and; ► believe the information to be true, accurate , and completek N <br /> Photos —Paperwork _Statement <br /> 3 . I am authorized to submit this certification on behalf of the Respondent. <br /> t am Possibility aware that there are significant penalties for submitting false information , including the <br /> 41 iIMprisonment for known violations . ( NSC 25191 ) p ►ty of a fine and/ <br /> i <br /> N a nrl :Lale <br /> Title : J=�)2Tm��� <br /> Signature: / <br /> Date: <br /> OWED <br /> SEP 0 9 2019 <br /> pk <br /> ENVIRONI\ IEN "hAL HEAI "1' 11 <br /> DEPARTINIENT <br /> i <br /> 1868 (✓. Hazelton Avenue I Stockton , California 95205 i T 209 468- 3420 l F 209 464-0138 ■ <br /> I www. sjcehd, com ®■� ;' <br /> % <br /> %E <br /> ■ <br />