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M&Siq I A 57: <br />f <br />Must be R, O <br />receipt of this inspection. This certification form must be �Itted to the Environmental Health Department (EHD) address, <br />the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br />All OOM%tons to goer vioMgns noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certation and returned to EHD WlBIQAM unless otherwise specified in the <br />Inspection Report. HSC 251 Wc)(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 />Inspection Date: September 08, 2015 Inspected BY: FATINAH ZAREEF <br />Facility Address: 3425 N TRACY BLVD, TRACY EPA 111. <br />I certify under penally of law that <br />1. 1 have -corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />b--aOVQ <br />OE. I have personally examined the following documentation submitted as peroof �Of FOR EACHVIMOILATI 101 <br />I believe the infiormation to be true, accurate, and complete. <br />Photos --,X—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 submitling false in1brination, including the possibility of a fine <br />imprisonment for known violations. (HSC 25191) <br />Va-itw. 1�14.'/&41 So"'AM'k We- 4ud 1 len et towdin <br />Malin <br />Yl,,VXY'T a -ti, aY,-, C&t4 r -Z -A -/- aept-AOL <br />LA 0 <br />d' U <br />VO <br />0 <br />jo7-C, <br />P-1 <br />� .�.- v� 'v ` C t `� , -� _ °11.1 <br />�Uw +0 P -Y' 0 U'a <br />