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SAN 10AQUIN Environmental Health Department <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 billed <br /> 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: May 27 , 2020 Inspected By : PAUL NSO <br /> Facility Address : 419 S MAIN ST, MANTECA CERS ID : 10181307 <br /> I 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 ✓ Paperwork ✓ 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 . lett SA11N#1 10 " A J 1 Title: . /?� tis � r>� ti ; <br /> Signature : `�?T� — ' Date: _ / - .3 - J <br />