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T <br /> Sari JoaquinCounty RECEIVED <br /> Envircnment&: Healtn DepartMent <br /> 1868 E=ast Haze!ton Avg :i::r. . tec�.tcrr; Califomia 95205-6232 JAN 2 3 2017 <br /> Tel phone:(209)458-5420 =Fax.(2:09)458-3433 Neta:www.si�Lov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> RE TURN TO CvMWL!ANCE CERTIFICATION PERMIT/SERVICES <br /> Any MINOR violations noted in the'Notice to Comply"ire the attached inspection Repert must be corrected within 30 days of <br /> receipt of this inspection. This certi cation form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 day of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations no ed 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 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3 <br /> Note: All EHD staff time as ociated with failing to comply by the above noted dates will be <br /> billed at the current h urly rate. <br /> Or ��:r, .c:r•,-.._+•-... - s...,.-, <br /> I err t:ria %ei i icaatior i to be co i�Nralc, the operator of the site must inciude: <br /> A statement documenting� hat corrective actions were taker,or will be taken for each violation <br /> Copies of sample results/m nifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Inspection Date: November 14, 2016 Inspected By: FATINAH ZAREEF <br /> Facility Address: 7939 E ELEVENTH ST, TRACY CERS ID: 0 <br /> 1 certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection R;:port from the above-mentioned inspection date. <br /> 2. 1 have personaliy examined the following documentation submitted as proof of corrnpliance FOR EACH VIOLATION <br /> and I believe the informatioii to be true, accurate, and compete <br /> I _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 s gnificant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) r <br /> Name:��� D1MA S Title: Q�' U' <br /> Signature: --Date: . 1-2-�` — <br /> i <br />