Laserfiche WebLink
S A N ] 0 A Q U I N Environmental Health Department <br /> C(IN1Y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to ComplI In the attached Inspection Report must be corrected within 30 claws 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 EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(e)(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 resultstmanifesis/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> ,: . Inspected By: STACY RIVERA <br /> Inspection Date: May 24, 2023 <br /> MANTECA CERS ID: 10184191 <br /> �� . Facility Address: 1330 E YOSEMITE AVE , <br /> I certify under penalty of law that: <br /> Wlliiitii Al 1 . I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> ► �: x <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> r " <br /> + ' and I believe the information to be true, accurate, and complete;. <br /> Photos 0 Paperwork Statement <br /> r , 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> e" 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 violations. (HSC 25191 ) <br /> ��• Title: <br /> m Name:_ <br /> Date: <br /> Signature: <br /> r <br /> i <br /> �s <br />