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RECEIVED FEB 062019 <br /> SAN J U A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness „ .F I ` ^ re . <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 <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/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date : February 06 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address : 1234 E YOSEMITE AVE , MANTECA CERS ID : 10184299 <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 /> /7 <br /> Photos Paperwork Statement <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 : Deborah <br /> Rowe Title : UST Compliance Coordinator <br /> Signature : Date : 2/22/2019 <br /> 1868 E Hazelton Avenue I Stockton , California 95205 T 209 468 -3420 F 209 464 -0138 1 www. sjcehd . com <br />