Laserfiche WebLink
Environmental Health Department <br />SAJOAQUIN <br />1-.,.I —COUNTY- - <br />Greatness yrows h,eic, <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR 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 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 />For this certification to be complete, the operator offfiesitemustinclude: <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: , August 13 2024 Inspected By: MARIA LOPEZ <br />Facility Address: 1700 E YOSEMITE AVE, MANTECA CERS ID: 10181431 <br />I cert <br />ify under penalty of law that: <br />1. I have corrected the violations speciFlad 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, ZStatement <br />3. I am authorized to submit this cert <br />ification 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 andlor <br />Imprisonment for known violations. (HSC 25191) <br />Name:.'U r%1 LA=L / L812 Title:�A`,n�,` <br />e�� %—Date: <br />Signature: <br />