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SAN l0AQ UIN Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the Notice fo mo mulst bethe submitted e o Ithe Ennspectviironion Rmen eport al Health must eDepartment ( EHD addresscorrected within 30 days f at <br /> receipt of this inspection . This certification <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404 . 1 . 2 (c )( 1 ) <br /> on Form , <br /> or disputes to any <br /> All corrections to other <br /> violations <br /> d ot acat ohn and retumedReport <br /> to EHD w thin 30 days unless otherwiserwise spec f ed in the <br /> violations , are to be submitted using g this certification <br /> Inspection Report. HSC 25185(c)(3) <br /> Note : All EHD staff time associated with failing to comply by <br /> the above noted dates will be billed <br /> i' at the current hourly rate . <br /> For this certification to be complete , the operator of the site must include : <br /> A statement documenting what tive records/othens were r appken �oprialbe taken te paperwo�keand `orach ophootos verifying corrections <br /> Copies of sample results/manifests/training <br /> • Operator's certification <br /> Inspected By : PAUL NSO <br /> Inspection Date: May 27 , 2020 <br /> Facility Address : 419 S MAIN ST, MANTECA <br /> CERS ID : 10181307 <br /> WIN WE <br /> I certify under penalty of law that: <br /> ied in the Inspection Report from the above- mentioned inspection date . <br /> 1 . I have corrected the violations specif <br /> 2 . I have personally examined the following document andfcomplete :ifted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true , accurate , <br /> Photos ✓ Paperwork <br /> ✓ Statement <br /> 3. 1 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 : tlaCCA � n/ < i >7A , <br /> Title: <br /> Signature: <br /> ----�j Date: <br />