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Environ ental Health Department <br /> SAN JOAQUIN <br /> e <br /> -� COUNTY <br /> �'���►�� Greotness grows hire. <br /> RETURN TQ COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "notice to Comply" in the attached Inspection Report must be corrected within 30 da s of <br /> receipt of this inspection. This certification farm must be submitted to the Env*ironmental Health Department (EHD) address at <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 Hated 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 da sunless otherwise specified in the <br /> Inspection Report. HSC 25'185(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 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 verifying corrections <br /> • <br /> Operat&s certification <br /> Inspection Date : April27 , 2023 Inspected By : KRISTINA SAETERN <br /> Facility Address : 24323 N HWY 99 , ACAMPO CERS ID : 10181611 <br /> 1 r <br /> tify under penalty of law that: <br /> 7 . f have corrected the violations specified in the Inspection Report from the above-mentioned inspection date . <br /> 2 . 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and ! believe the information to be true, accurate, and complete: <br /> VPhotos V. - -Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent, <br /> 4. I 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 � I. � � Title: <br /> . e <br /> Z 3 <br /> Signature: Date : � <br />