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A NJ OAQ U 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 Report HSC 25404.12(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 <br /> billed 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 resultslmanifestsltraining records/other appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: March 03, 2022 Inspected By: PAUL NSO <br /> Facility Address: 469 MOFFAT BLVD STE C, MANTECA CERS ID: 10187029 <br /> 1 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 submhted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true,accurate,and,complete.- / <br /> Photos 1 Paperwork Y Statement <br /> 3. 1 am authorized to submit this cefification 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 imprisonment for known violations. (HSC 25191) <br /> Name: 1, Title: owiNCA' <br /> Signature: Date:�-3—2-9-ZL?2 <br />