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911E 'IN AJ d UH '�0A auil Pania)aa <br /> SANJOAQUIN Environmental Health Department <br /> c o u of•r Y—. <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 lathe Environmental Health Department(EMD)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 g9rrections to ot"r vIoladQ121 noted in the attached Inspection Report(IR)or Continuatlan 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: February 16, 2018 Inspected By: BETTY HO <br /> Facility Address: 3775 N TRACY BLVD, TRACY CERS ID: 10161337 <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 dale. <br /> 2. 1 have personally ex3minod the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I belleve the information to be truo, accurate, and complete; <br /> Photos L✓ Paperwork ✓ Statement L-')e LX- e <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 submitting false Information.including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name�� t Title: OWrUL �r,,n r)r�n �,j,✓ <br /> Signature: %A'C L vA Date: � ��� -zo(g <br /> RECEIVED <br /> MAR 13 2018 <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> 1868 E. Hazelton Avenue Stockton.California 95205 i T 209 468.3420 I F 209 454-0138 1 www,sjcohd.com to■ <br /> EA d << ZL£ZZEWZ6 dOlS NOflbl AOVbl SS:26 £6 -£0-8Lm <br />