Laserfiche WebLink
" SAN I OAQ U I N Environmental Health Department <br /> 1 ,�t � UUINIY <br /> i ` <br /> Grrat,ress q+-ows here!. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply"in the attached Inspection Report must be corrected within 0 p of <br /> receipt of this Inspection. This ceriificaiion 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 254D4,1.2(c)(1) <br /> All corrections to other violations noted in the attached inspection Report(Ifs)or Continuation Form,or disputes to any <br /> violations.are to be submitted using this cert+fication and returned to EHD within 30 da ys 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 hourly rate. <br /> For this certification to be complete, the operatorof thesite must include: <br /> A statement documenting What corrective actions were taken OF will be taken for each violation <br /> Copies of sample resultslmanifestsltraining recordslother appropriate paperwork.and/or photos verifying corrections <br /> Operator's certirication <br /> inspection Date: May 24, 2023 Inspected By: <br /> STACY RIVERA <br /> .�,�,•�'� Facility Address: <br /> 9330 E YOSEMITE AVE,MANTECA CERS lD: 10184191 <br /> I certify under penalty of law that: <br /> r� <br /> 1- I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2, l have personally examined the following documentation submitled as proof of compliance FOR EACH VIOLATION <br /> • 'AC <br /> �. • ,� �� and I believe the information to he true.accurate,and compete; <br /> Photos Paperwork Statement <br /> lip <br /> s s 4+ 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> t+ 4. 1 am aware Ihat there are significant penaIIWS for submitting false information,including the possibility of a fine <br /> andlor imprisonment for known violations. (HSC 25191) <br /> m� r Title: <br /> Z� Name' <br /> c Idate: y <br /> Signature: <br /> r <br /> 1 <br /> a <br /> r <br /> Y <br /> f <br />