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SAN WOUIN Environmental It Department <br /> RETURN TO PLi CE CERTIFICATION <br /> I <br /> AnyIM NOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 day§ of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department (EHD ) address <br /> at 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 /> F® r this certification t® 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/manifestsltraining records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Dates. August 13, 2019 Inspected Bya PAUL NSO <br /> Facility Address : 430 W Center St , Manteca CERS ID: 10141507 <br /> 1 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 . 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 X 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 and/ <br /> imprisonment for known violations. ( HSC 25191 ) <br /> Name: Masood Choudhu Title: Manager - West Legion, Environmental <br /> Signature: Date: April 15 , 2021 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www . sjcehd. com <br />