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ll0ti ' ° NWdSti 0 6lOZ 106 ' APA awil p ; Aia � a � <br /> , uf Environmental Health Department <br /> .Pod P ; ; <br /> . � <br /> � <br /> Le r C <br /> t : ., O V T Y�- <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted In the "Notice to Comply" In the ottachod Inspection Report must be cor t d within , da sof <br /> receipt of this Inspection. This Certification form must be submitted to the Environmental Health Department (END ) addross <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404 , 112 (c) ( 1 ) <br /> A11I gorrections IQ other violallons, 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 unles 2 e0i cifged In-it e <br /> Inspoction Report, HSC 25185 (c)(3 ) <br /> % - L1 D <br /> Note : All EHD staff time associated with failing to comply by the above noted dates ` ��I � 0 <br /> billed at the current hourly rate. 2019 <br /> For this certification to be Complete , the operator of the site must Include ; ENVIRONMENTAL HEALTH <br /> A statement documenting what corrective actions were takon or will be taken for each violation DEPARTMENT <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 22 , 2019 Inspected By : ZONA BARKER <br /> Facility Address : 3775 N TRACY BLVD , TRACY CERS ID : 10181337 <br /> I certify under penalty of law that: <br /> 1 . I 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 Paperwork toddoe Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4 . 1 am aware that there aro significant penalties for submitting false Information , Including the possibility of a fine <br /> end/or imprisonment for known violations , ( HSC 25191 ) <br /> Name : ti4Q t Fe.. L t Title : CAA) &S r add (7 / <br /> Signatur s><✓ `� -� -�- Data : 3 ;L2xj <br /> SE.c. •E-, ,fl•�.. �O �1 � O t� RA h.p ••�-�� .e� C� �- a � � S 5 � �s t v� cJ�-t.� <br /> V\O"t� r C -�� v -�'e� Ov.�. _C� v k\ 40 w �o <br /> 5ecf �oN. 3� q gA\\ v�-dd R4do v, JL.a,.� czA ..s LAD 6L6 <br /> 2g n d2-do'? Code, <br /> st0. 0v^ U.aov) <br /> OW AO r �s kJ -� raw. "o 1 t le 12.01 fa , <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-34201 F 209 4640138 1 www, sjcohd. corn <br /> ■ <br /> L / L d < < Z6 £ ZZ £86021 dO1S Jon do ov i <br />