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SAN J OA Q U I N Environmental Health Department <br /> C_C)11 �1T Y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINORviolations noted in the"Notice to Comply"In the attached Inspection Report must be of l <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Dopartmont(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 usingthis certification and returned to EHD within 30 days unless otherwise specified In the I <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 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: December 21,2021 Inspected By: KRISTINA SAETERN <br /> Facility Address: 1097 YOSEMITE AVE, ESCALON CERS ID: 10180561 <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—V—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: ZLZ42;7 &/� Title:_ 42W/J�O <br /> Signature: ! Date:1 D 2 <br />