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SAN J U A Q U i N Environmental Health Department <br />C)UNTY <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report must be corrected v <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department <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 disc <br />violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates <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 <br />Operator's certification <br />Inspection Date: <br />Facility Address: <br />March 09, 2021 <br />25533 N HWY 99 RD, ACAMPO <br />I certify under penalty of law that: <br />Inspected By: C <br />CERS ID <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />0 days of <br />address at <br />to any <br />ified in the <br />be billed <br />/erlfying corrections <br />I <br />A JDIA MURO <br />10183911 <br />)edlon date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <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. 1 am aware that there are significant penalties for submitting false information, including the I <br />and/or imprisonme t for known violations. (HSC 25191) <br />Name: Title: OW,4-)En <br />Signature: Date: <br />Received by the SJCEHD <br />(CM) on 05/18/2021 <br />H VIOLATION <br />of a fine <br />