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ZL6 ' ON WVZI � IG 8lOZ Zl ' } � 0 auall paAl ; ) ; <br /> IS A N J 0 A 0 U I N Environmental Health Department <br /> t �ti . . . . . . <br /> 16 <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 <br /> at the top 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 results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date : August 30 , 2016 <br /> Inspected Isy : ZUNA BARKER <br /> Facility Address : 1229 E LOUIS :. AVE , MANTECA <br /> CERS ID : 10186837 <br /> I 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 . 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 �PaperworXk 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 25191 ) <br /> Name : <br /> Title : <br /> Signature : f" _ <br /> -Date : / 6 � Z <br /> OCT 12 2018 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www. sjcehd .com ■ ■ <br /> ■ <br /> abed xed dH 8Ei I. 6 2 60Z 90 0® <br />