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5 A N J O A Q U I N 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 violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : March 26 , 2020 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 2615 W GRANT LINE RD , TRACY CERS ID : 10184725 <br /> I certify under penalty of law that: <br /> 1 . 1 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 y Paperwork 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 and/or <br /> imprisonment forknownviolations , ( HSC 25191 ) 'G �- �' / (o YTS ( - U C� <br /> J\/[ <br /> Name : 9/ // 8 ^c)k rJ C. .r N I Title :_ " Ca iL�r9 w l let. f, ' <br /> Signature : � , � � � o - Date : 0 <br />