Laserfiche WebLink
' AJ ) AQUIN Environmental Health Department <br /> t . ; CCS N f" Y <br /> bT <br /> t1 L A <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted n the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection . Th ; 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. NSC 25404. 1 . 2(c)( 1 ) <br /> All corrections to other violati ns noted In the attached Inspection Report (IR ) or Continuation Form , or disputes to any <br /> violations , are to be submitte I using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report, HSC 251 , 5(c)(3 ) <br /> Note , All EHD staf ' time associated with failing to comply by the above noted dates will be <br /> billed at the cur ent hourly rate. <br /> For this certificatio n to be complete , the operator of the site must include : <br /> A statement docurrI riling what corrective actions were taken or will be taken for each violation <br /> Copies of sample re ;tilts/manifests/training records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certilica5 m <br /> Inspection Date : t4oyember 01 , 2019 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 15 E GRANT LINE RD , TRACY CERS ID : 10181019 <br /> certify under penalty of law that: <br /> 1 . I have corrected th violations specified in the Inspection Report from the above-mentioned inspection date . <br /> 2 . I have personally , xamined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the in ormation to be true , accurate, and complete: <br /> Photos ;K PaperworkStatement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that th :re are significant penalties for submitting false information , including the possibility of a fine and/or <br /> Imprisonment for k.i own violations. (HSC 25191 ) <br /> Name : y+C c t 'n Title : SeCr6 Cc <br /> Signature : Date : <br /> i <br /> E <br /> E <br />