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Environmental Health Department <br />SANJOAOUIN <br />�E .. <br />RET RN TO COMPLIANCE CERTIFICATION <br />y MINOR violations noted in the "Noti e to Comply" in the attached Inspection Report must be corrected within 30 days of <br />reipt of this inspection. This certificati n form must be submitted to the Environmental Health Department (EHD) address at <br />It bottom of this form within 30 days o receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />icorrections to other violations noted the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />v <br />lations, are to be submitted using thi certification and returned to EHD within 30 days unless otherwise specified in the <br />I pection Report. HSC 25185(c)(3) <br />ote: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hou iy rate. <br />r this certification to bE complete, the operator of the site must include: <br />A statement documenting wha corrective actions were taken or will be taken for each violation <br />Copies of sample results/mani ests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />on Date: October 2p, 2024 Inspected By <br />ility Address: 700 N MAIN ST, MANTECA <br />certify under penalty of law that: <br />MICHAEL SUSZYCKI <br />CERS ID: 10182171 <br />1. 1 have corrected the violation# specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined ]he following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the information jo be true, accurate, and complete: <br />Photos _Paperwork Statement <br />3. 1 am authorized to submit thils certification on behalf of the Respondent. <br />4. 1 am aware that there are si nificant penalties for submitting false information, including the possibility of a fine and/or <br />imprisonment for known viol tions. (HSC 25191) <br />Name: AAi CA Title: jaig <br />j <br />Date: _ Z Z / <br />Signature: — <br />