Laserfiche WebLink
OmAX NO. Aug. 14 2018 06:14AM P1 <br /> RECF4WEDF <br /> AU6 13 2018 <br /> ENVIRONMENTAL HEALTH <br /> S <br /> E ' Environmental Health Department A t( A�N <br /> COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MlblQI3 violations noted in the"Notice to Comply"in the attached Inspection Report must be ggmcted wilhip3"ays 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 g=dgna to otherviolationsnoted 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 9M unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EKD 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/man Ifests/train Ing records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date; July 11, 2018 inspected By: ZUNA BARKER <br /> Facility Address: 515 W ELEVENTH ST, TRACY CERS ID' 10181209 <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 f�_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 fins <br /> and/or imprisonment for known violations, (HSC 25191) <br /> Name: V) cc C)X, Title:— qq q <br /> Signature: Date: 13-t <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcohd.com <br /> Received Time Aug. 14, 2018 6 : 13AM No. 4010 <br />