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Environmental Health Department <br /> `kSil NIN <br /> t tlt � COUNTY . _ _. <br /> 3 dh t. a <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 /> ation and returned to EHD within 30 days unless otherwise specified in the <br /> violations , are to be submitted using this certific <br /> Inspection Report . HSC 25185 (c) (3) <br /> Note : All EMD 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 : August 16 , 2021 Inspected By : PAUL_ NSO <br /> Facility Address : 1700 E YOSEMITE AVE , <br /> MANTECA CERS ID : 10181431 <br /> 1111 11 11 <br /> WIN <br /> I certify under penalty of law that: <br /> 1 . I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date . <br /> 2 . I 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 Statement <br /> 3 . I am authorized to submit this certification on behalf of the Respondent . <br /> 4 . I am aware that there are significant penalties for submitting false information , including the possibility of a fine <br /> and/or imprisonment for known violation ( HSC 25191 ) <br /> VsIIII <br /> Title : /Ze <br /> Name : <br /> Signature : <br /> �- `� Date : <br /> 11 11 1 MEN IN= I WINE <br />