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5 A N A U N Environmental Health Department <br /> C 0 U iusl 1� Y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the °Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification 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 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/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : July 10 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address : 983 Moffat Blvd Manteca CERS ID : 10132636 <br /> I certify under penalty of law that: 1 <br /> 1 . I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2, t 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 /> f <br /> Photos Paperwork Statement i <br /> 3. 1 am authorized to submit this certification 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 ) <br /> Name: A.N �- Title :t o M pL( A NCS AnM liV l S7 " Tf�� <br /> t q , <br /> Signature: a� Date: <br /> 1868 E . Hazelton Avenue I Stockton , California 952051 T 209 468-34201 F 209 464-0138 I www.sjcehd. com <br />