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� � �D��UI � 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 days 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 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 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 vlolatlon <br /> Copies of sample resullslmanifestsltralning recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: January 31, 2020 Inspected By: JASON GAITAN i <br /> Facility Address: 1775 W L DWELL,AVE, TRACY CERS ID: 10184151 <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 V Paperwork V statement <br /> 3, i 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 and/or <br /> imprisonment for known violations. (HSC 25191) <br /> Name: Casey J. Goodall Title: Associate Superintendent for <br /> Business Services <br /> Signatur Date:. 2l 1.2-0 _ i <br />