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i <br /> : . JOANI <br /> Environmental Health Department <br /> c U hi T Y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQ$violations noted in the"Notics 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(t=HD) address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404-1.2(c)(1) <br /> Ail corracGons_W.other violations rioted in the aitachad 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 0 ao unless otharwlse specified 1n the <br /> Inspeotlon Report. HEC 25185(c)(3) <br /> Note; All EHb staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> Forth is certification to be ccm plot , the operator of the site must include: <br /> A statement documenting vuhat corrective actions were taken or will be taken for each violation <br /> Copies of sample resultsfmanifestsItrain ing recordsfother appropriate paperwork, andior photos verifying corrections <br /> Operator's certification <br /> Inspection Date: September 17, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 4310 Arch Rd, Stock#on CERS ID: 10142375 <br /> certify under penalty of law that; <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection data. <br /> 2, 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I helieve the information to be true, accurate, and complete: <br /> Photos Paperwork2L—Statament <br /> 3. 1 am authorized to submit this certification on behalf of the Respondant, <br /> 4. 1 am aware that there are significant penalties for submitting false information, Including the possibility of a fine andA <br /> imprisonment for known violations. (HSC 25191) <br /> Name: Mmnd°*zW1mk W00 Title; <br /> Signature: _Date: <br />