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BIVI � nO1fTflental Health Department <br /> SAN 1JHQUiN <br /> r214wtile <br /> . <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M1UH violations noted in the " Notice to Comply in the attached Inspection Report must be corrected withln 30 dnyq of <br /> recelpt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD) address i <br /> the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404 . 1 . 2(c) (1 ) <br /> All corrections toothg>_ IQt14ns notod In the attached Inspection Report (IR) or Continuation Form , or disputes to any <br /> violations , are to be submitted using tills 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 res ults/manifeststlraining records/other appropriate paperwork , and/or photos verifying corrections <br /> • Operator's certification <br /> Inspection Date: June 11, 2019 Inspected By : PAUL NSO <br /> Facility Address : 505 N MAIN ST, MANTECA CERS ID: 10182 / 07 <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. 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 AStatement <br /> 3 . I am authorized to submit this certification on behalf of the Respondent . <br /> 4 . I 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 : LCL � � e Title: <br /> Signature : :l> Date: .i c <br /> REGER <br /> ENIViRONN E1AAL I i1~ ALY <br /> 1868 E . I •lazollon Avenue 1 Stockton , California 96205 1 T 2.09 468"31201 11 2.09 464 JV4 i1 l ��Ilconl <br />