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0 A Environmental Health Djqpartment <br /> 7- N <br /> E C­ OAOUIN <br /> 'J <br /> C:LJ <br /> YV,,N 15 2018 <br /> RETURN TO COMPLIANCE CERTIFICATION ENVIRONMENTAL <br /> Any MINQR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 3d&y5'of: DFPARTMENT <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(FHD)address <br /> at the top of this form within 30 days of receipt of the inspection Report. HSC 25404.1.2(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 results/manife-sts/training recordslother appropriate paperwork,and/or photos verifying <br /> corrections <br /> operator's certification <br /> Inspection Date; May 15, 2018 Inspected By: LYDIA BAKER <br /> Facility Address: 1130 N MAIN S7, MANTECA CERS ID, 10181367 <br /> I 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 submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true,accurate, and complete: <br /> I <br /> _Photos �K paperwork Statement <br /> 4A <br /> 3, 1 am authorized to submit this ceificatlon 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) Title: <br /> Name: A& <br /> Signature:_k Date: <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 2094,68-34201 F 209464-01'38 1 www.sjc--I)d.com <br /> TO 39VId 3aois sin 3Hi Z90Z5718160Z 9S:tT 8TK/ST/90 <br />