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11i07/2017 15:90 20929 <br />%E <br />'r <br />it <br />SAN_JOAQUIN <br />COUNTY <br />A ONE GAS PAGE 01/02 <br />al <br />Environmental Health Department <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 da.,yg of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br />All correc igns 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 wi hin 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 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 <br />corrections <br />Operator's certification <br />Inspection Date: November 02, 2017 _ Inspected By: BETTY HO <br />Facility Address: 574 W GRANT LINE RD, TRACY CERS ID: 10181065 <br />1 certify under penalty of law that: <br />1. I 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 <br />and/or imprisonment for known violations. (HSC 25191) <br />l <br />Name: 72 <br />Title: <br />Signature: f <br />Date: <br />RLCEIVEO <br />NUV U > ivlr <br />�EWRONWA'41 fAL FWALTH <br />PERW/SERMICES <br />1865 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjoehd.com <br />Received Time Nov, 7, 2017 3:28PM No -2540 <br />