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w _ <br /> it <br /> 4 <br /> C• <br /> SAN JOAQU1N � Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted In the"Notice to Comply"in the attached Inspection Report must be corrected will 30 days of <br /> receipt of this inspection-This certification form must be submitted to the Environmental Health Department(EHO)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report- HSC 25404.1.2(0){7) <br /> All corections to other violations noted in the attached Inspection Report(IR)or Continuation Farm,or disputes to any <br /> violations,are to be submitted using this cer4hcation and returned to El within 30 days unless otherwise specified in the <br /> Inspection Report, HSC 25185(0)(3) <br /> Note: All Ell staff time associated with tailing to comply by the above noted dates will be billed <br /> at the current hourly rate. t <br /> For this certification to be complete,theoperatofofthesuemustinclude. i <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample result5rmandestsi raining recordarother appmpdate paperwork,andlor photos verifying corrections <br /> Operator's certification <br /> �' <br /> Inspection Date: <br /> Janua 21,2021 Inspected 8y: KRiSIT,NASAETERN <br /> CERS ID: <br /> Facility Address: 1410 COLONY RC,RIPON <br /> 10184831 <br /> I certify under penalty of law that. <br /> 1. 1 have corrected the violations specned in the Inspection Report from the above mentroned inspedion date <br /> 2 and I be ersothe in GX.111i the <br /> on to bet ei documentation submitted as proof of compliance FOR EACH VIOLATION <br /> , lhava <br /> and <br /> Photos Paperwork Statement <br /> 3 I am authorized to submit this certification on behalf Of the Respondent <br /> q, V am aware that there are significant penalties for submitting false infam.stioh,including the possibility of a fine <br /> (HSC 25191] <br /> andlor im risonment for known violations- <br /> t � � Title: — <br /> Nam <br /> Signature: <br /> 1 ',2 <br /> y <br /> J <br />