Laserfiche WebLink
IRECEIVI <br /> Environmental Health Department, <br /> SANtA AQUIN <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIND R 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 /> violations,are to be submitted using this certification and returned to END within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25165(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/trainuig records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 01, 2021 Inspected By: NICHOLAS LOEHRER <br /> Facility Address: 1650 W YOSEMITE AVE BLDG 2, MANTECA CERS ID: 10/87245 <br /> 1 cert,fy 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_,_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/or <br /> imprisonment for known violations (HSC 25191) <br /> " <br /> Name: Title: <br /> Signature: s /`? Date: <br /> z. <br /> A K H <br /> 6 z k • <br /> 4 <br /> t <br />