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Environmental Health Department <br /> E rW <br /> , - <br /> : t � � <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 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 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 resuits/manifestsftraining recordslother appropriate paperwork, and/or photos verifying corrections <br /> • Operator's certification <br /> Inspection Date: November 03, 2021 Inspected Sy: SHEWIT WOLDEAREGAY <br /> Facility Address: 1330 E YOSEMITE AVE , MANTECA CERS ID * 10184191 <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 compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete*. <br /> Photos r/ Paperwork r/ 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: v Title: ?J0 <br /> Signature: Date: <br />