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.:� � .� -� <br />,. <br />r . • �� � � <br />.�� ...r <br />{ t; <br />,I���.�._, � � �p19 <br />Any MIiVO� violations noted in the "Notice to Cpmply" in the attached Inspection Report must be corrected within 3Q �1�s of <br />receipt of this inspection. This certifcaflon 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 corrections to otherviolaiions 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 �i� unless otherwise specified In the <br />Inspection Report. HSC 25185(c)(3) <br />{�lcete: �;ii SMD staff tim® associated with failing to compiy by the above noted'dates vv9lil be <br />biiied at Lite current hourly rate. <br />For $h iS ��I�tIfi1G��ipn fio b@ COCT1pi2tt;, the operator of thg site must include: <br />• A statement documenting what corrective actions were taken or will be taken for each viglation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Irsspection 4at€�: <br />EaciEitg� a�dcf rasa; <br />December 19.2018 <br />Inspected iay: <br />7501 W ELEVENTH ST, Tracy CERS Ib: <br />I cortify under penalty of law that: <br />NICHOLAS LOEHRER <br />10509163 <br />1. I have corrected the violations specrfed in the Inspection Report from the above-mentioned inspection data. <br />2, ! ha•✓e personally examined the following documentation submitted as proof of compliance FOR EACH VIOLl1TION <br />and I believe the information to be true, accurate, and Complete: <br />Photos i./ .Paperwork � Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there ar© slgnEflcant p®nalties for submitting false Information, including the possibility of a fine <br />andlor impl'isonment for known violations. (HSC 25191) <br />NCame:� i�V r � 7 �2 � ��� l_�1,, -, Title:— �! <br />Signar�ire: � �� � � �.� Date: l I _Z � � � (Gi �.� <br />9863 �. I�azelton Avenue � Stockton, California 95205 J 7 209 �i68-3420 i F 209 464-0138 � www.sjcehd,com <br />Received Tirne Jan, 21. 2019 11:OlAM No. 4625 <br />