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ulil pan <br /> 98titi ' 0N Wdlti 01 810SAN <br /> Z 5 aaQ aiaaaa <br /> IN <br /> Environm JOAOU <br /> ,�r Health Dirt x <br /> - - - 00U NTY - - _ <br /> 2018 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> NVI i p/6 6 "pal HEALTH <br /> . <br /> Any MINOR violations noted in the "Notice to Comply° in the attached Inspection Report must be correcte&W`itj6W1 --1 f tf Rf I T" <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 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 violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date : November 27 , 2018 Inspected By : ZONA BARKER <br /> Facility Address : 1420 N Tracy Blvd , Tracy CERS ID : 10397599 <br /> I csrtify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in thed 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 Paperwork x 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 possibility of a fine <br /> and/or imprisonment for known violations. ( HSC 25191 ) / <br /> Named kicino'Dj ra -- if n0 Title . M W t/1� LN{0.a p <br /> C ` <br /> Signature: _Date: <br /> V l T vjN it be, 1-09in � t � +0 CCrs 0A OIL ( rvtakc e$ 66vx s _ <br /> 0n4 off - wLt1 t� Pda�B - u-f� \ivv► p (oYeze "tQl ^-8 ;or tO 4o n2aw -V' rm <br /> ro rY1 @� A G� �t o� tom ' o n S V� � n <br /> 01i - V a,4Q Will -�rowt ~� Li� d owarG L UJ t, t ,4k iA q6 Av✓ 6 ' v► QCJr ;lt,oh <br /> 1868 E . Hazelton Avenue 1 Stockton , California 952051 T 209 46834201 F 209 464-0138 1 www. sjcehd . com <br /> l ' d 8860 ' ON [ � JidSOH ADPAI aa } jnS AVL ' 01 210Z ' S aaQ <br />