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SAN IA Q U I N Environmental Health Department <br /> z-A: _01.) r.lTY <br /> Received by the SJCEHD (CM) <br /> on 05/10/2021 <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 the <br /> form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 3days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violationi' 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 hour, ly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documen ng what corrective actions were taken or will be taken for each violation <br /> Copies of sample resu is/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification, <br /> i <br /> Inspection Date: Math 09, 2021 inspected By: CLAUDIA MURO <br /> i <br /> Facility Address: 255. 0 N HWY 99, Acampo CERS ID: 10422952 <br /> 1 certify under penalty of law th I <br /> t. <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally exanmed the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true,accurate,and complete: v <br /> Photos Paperwork X 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 <br /> and/or imprisonm t fdr known violations. (HSC 25191) <br /> t� JAI/+-GG <br /> Name: Title: lez-0ov��Z <br /> Signature: Date: Z Z� <br /> i <br /> i <br /> I <br /> I <br /> i <br /> i <br />