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I Environmental Health Department <br /> SANJOAOU <br /> UIT - <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be tin30 da of <br /> receipt of this inspection. This certification form must be submitted to the Environmant8l Health Depsrtrnent(EHD) address at <br /> 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 vlolations noted in the attached Inspection Report (IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this cerlirication and returned to EHD wit1hIn 30 daysdays unless otherwise specified in the <br /> Inspection Report. H SC 25165(c)(3) <br /> Note: All EHb staff time associated with failing to corttply by the above Mated dates will be <br /> billed at the currernt 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 vialat.ion <br /> Copies of sampie resultsfmanifestslkaining record Wather appropriate paperwork, and lor photos verilfying corrections <br /> Operator's certification <br /> Inspection Date; September 16, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 2323 GRAND CANAL BLVD, STOCK-FON CERS ID: 10144769 <br /> 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 ccnnpliance FOR EACH VI0LAT 1ON <br /> and t begeve the mturmation to be true, aocurate, arrd complete. <br /> Photos Paperwork Statement ; <br /> 3. 1 am authorized to suhmit this certification on behalf of the Respondent. <br /> 4. 1 am awarri that there are significant penalties for submitting false information, Including The possibility of a fine andfc ' <br /> imprisonmFdnt for known violations_ (HSC 25191) <br /> MW�"'d'o'"�l�l�l cc�rrp9�ncs <br /> Name: Title: <br /> signature: Date: <br />