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SAN J O AN I N 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 Repot_ HSC 25404,1.2(c)(1) <br /> All rwreclions to other violations noted in the attached Inspection Report jIR)or Continuation Form,or disputes to any <br /> .Mal,ons. are to he submitted using this certification and retttrniad to EHD within 30 mays unless otherwise specified in the <br /> Insperfton Report, HSC 25185(c)(3) <br /> Mote: 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 stawment rfocumenung what corrective actions were taken or will be taken for each violation <br /> Copies of sample resultslmanifesWirmning rocordslother appropriate paperwork anWor photos verifying corrections <br /> Operators certification <br /> Inspection Date: .January 05, 2022 Inspected By: KRiSTINA SAETERN <br /> Facility Address: 341 E MAIN ST, RIPON CERS ID: 10181381 <br /> 1 ratify under penalty of law that: <br /> 1. 1 have corrected the violaboris specified In the Inspection Report from the above-mentioned Inspecitotl date:. <br /> 2. 1 have personally examined the following documentatrnn submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true, accurate.and complete: <br /> Photos Paperwork_ Statement <br /> .X <br /> 3. 1 nm authorized to submit this certification on behalf of the Respondent. <br /> I am aware that there are significant panyltir:s for submitting false information, including Jho possibility of a fine <br /> andlor imprisonment for known violations. (HSC 251 11) <br /> Narize. 1i A L!�- �" A tj Cr L_ Title: <br /> I Signature. Bate: <br />