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J A NJ U A Q U I IU Environmental Health Department <br /> _.0 'UNTY _.. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIUM violations nnte.d in the'Notico to Comply"in the attached Inspection Report must tie con-Q910 wtthin 3o dAVs 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 ePrtifiration and rete vd to EHD Wth;n 30_day3 unless otherwise spedrfied 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 resultUrnanifests/Raining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: August 07, 2019 Inspected By: NICHOLAS LOEHRER <br /> Facility Address: 1131 Holly Dr, Tracy CERS ID: 10184261 <br /> 1 certify under penalty of law that <br /> 1. I have counuted 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 Psperwork X statemem <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 passibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: ff ir? Title:�� ivy r� /rl ni/2r' , 04,0/ ✓� <br /> Signature:- <br /> Date: S'�r1�7-� 2ol <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 ( www.sicehd,com <br /> Received Time Sep, 4, 2019 9: 14AM N0, 5443 <br />