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Environmental Health Department aA014 RETURN TO COMPLIANCE CERTIFICATION A %; MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corrected within 30 days of cc ; pt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD ) address at the bottorn of this form within 30 days of receipt of the Inspection Report. HSC 25404. 1 . 2(c)( 1 ) 41 ! corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form , or disputes to any violations , are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the ' nsl:ection Report. HSC 25185 (c)(3 ) Note : Ail EHD staff time associated with faJing to Comply iay the above noted dates will be billed at the current hourly rate . For this certification to be complete , the operator of the site must include : A statement documenting what corrective actions were: taken or will be taken for each violation Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections Operator's certification inspection Date : September 19 , 2022 Inspected By . PAUL NSO Facility address , 367 W LOUISE AVE , MANTECA CERS ID : 10184261 i cartify under penalty of law that: _�� _ . _• . .. _.t � f i 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date . I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete : Photos Paperwork Statement 9 3 . I am authorized to submit this certification on behalf of the Respondent. 4 . 1 am aware that there are significant penalties for submitting false information , including the possibility of a fine and/or imprisonment for known violations. ( HSC 25191 ) Name :_ --- i —_ Signature : � Date : {