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S Q N xJ OA Q U I N Environmental Health Department <br /> COUNTY <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 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 (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 corrections <br /> Operator's certification <br /> Inspection Date . April 29 , 2019 Inspected By: ZUNA BARKER <br /> Facility Address . 290 N MAIN ST, MANTECA CERS ID : 10181339 <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. 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 and/or <br /> imprisonment for known violations. (HSC 25191 ) <br /> Name: M A W t> CE E P rD�Or4 Title : OWN E2 . <br /> Signature: ���`^�'3 Date: -0 <br /> 1868 E . Hazelton Avenue I Stockton, California 952051 T 209 46&3420 ( F 209 464-0138 1 www.sjcehd .com <br /> Scanned with CamScanner <br />