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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stockton , California 95205-6232 <br /> Telephone: (209) 468.3420 Fax: (209)46&3433 Web: www _sigov. org/ehd ( �? <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 . d 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 flailing 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 /> Inspection Date : October 13 , 2016 inspected By : ELENA MANZO <br /> Facility Address : 2427 W YOSEMITE AVE , MANTECA CERS ID : 101 81189 <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 EACH VIOLATION <br /> and I believe the information to be true , accurate, and complete : <br /> A.Photos Paperwork _statement <br /> 3 : I am authorized to submit this certification on behalf of the Respondent. <br /> 4 . 1 am aware that there are significant penalties for submitting <br /> false information , including the possibility of a fine <br /> and/or imprisonment for known violations . (HSC 25191 ) <br /> Name. MARK CA100 Title: �� ��� f� Ir� � s� �1t� �l� � � a �� S <br /> Signature: <br /> � ��✓ Date, Ny�ew+ c� <br /> RECF <br /> DEC 02 2016 <br /> ENVIRONME IT AL 11 ALTH <br /> DEPAI '`=I" iVENT <br />