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BALANCE DUL $0.00 <br /> �., <br /> SAN ,O AQU IInt Environmental Health Departinvill�R _ <br /> CLUN 11' <br /> Vi'"tncss grows herf. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any A11viol <br /> receipt of ations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of <br /> this i <br /> the bottonspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> m of this form within 30 days of receipt of the Inspection Report. HSC 25404.1,2(c)(1) <br /> All corrections to other violation <br /> violations, are to s noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> be <br /> Inspection Re submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Report. HSC 25185(c)(3) <br /> Nate: 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 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: November 23, 2020 Inspected By: PAUL NSO <br /> Facility Address: 1330 E YOSEMITE AVE, MANTECA CERS ID: 10184191 <br /> 1 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 /> Photos Paperwork `l 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: Title: <br /> Signature: Date: /A11V2-0 <br /> National Petroleum SG#078-021169 <br />