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SAN JOAQUIN Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply'ir 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 vv ola:ior,s :noted in a e attached Inspection Report(iR)or Continuation Form,or disputes to any <br /> violations, are to be submitted using this certsiication 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 t,ou0y �ataa <br /> For, this CCI"tNficatiori to be esWT ` 6ta, tha opa:-ator 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 ceaificatior, <br /> Insbertion Date: 4lanuary 28.. 2021 Inspected By: STACY RIVERA <br /> r acility Address. LJt;ii V� vI v 7 jr°°_i f ! )! { L,-, SACC �TOPJ C.E;4S ID: 10181253 <br /> I certify under penalty of law that: <br /> 1. 1 nave corrected the violations seecifie-i in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 ava personally z ;i„e `r.e fcilov;i,-.c CCCumer.tatior su misted as proof of compliance FOR EACH VIOLATION <br /> and l oLliave;;18 iJll.Orrria`i0r7`C b�true, accurate, and comp;?te: / <br /> _Photos _Paperwork✓ Statement <br /> 3. 1 am authorized to submit this cer�ifica`.iorn on behalf of the Respondent. <br /> 4 am a :a:,'hat-he-e y,-_ '__ r :!_ ter= `r.ttir`•g fa se information, including the possibility of a fine and/or <br /> irnprisonl—..arit for knov.,c violations. (HSC 25191) <br /> I <br /> V Signature:.... Date: �2'j 1 ' <br />