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SAN 10 A Q U I N Environmental Health Department RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the ' Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection . This certification form must be submitted to the Environmental Health Department (EHD ) address at the bottom of this form within 30 days of receipt of the Inspection Report . HSC 25404 , 1 . 2 (c)( 1 ) All 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 Inspection Report, HSC 25185(c)(3) Note : All EHD staff time associated with falling to comply by 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 resultsfmanifests/training records/othor appropriate paperwork , and/or photos verifying corrections Operator's certification Inspection Date: December 17 , 2019 Inspected By : SHEWIT WOLDEAREGAY Facility Address : 16470 CAMBRIDGE ST , LATHROP CERS ID : 107797134 I certify under penalty of law that : 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 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 PapenvorkStatement 3 . 1 am authorized to submit this certification on behalf of the Respondent. 4 . 1 am aware that there aro significant penalties for submitting false information , including the possibility of a fine and/or imprisonment f forrkknown violations. ( HSC 25191 ) Q Name :_ Title : !1/Jca7"�Le Signature: 40 Date :