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C ,JOOy�•• AN <br /> X-N � [ Envi �� nmental Health Department <br /> '�'•i � ;;�sstij,' <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted In the " Notice to Comply" In the attached Inspectlon 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 : October 28 , 2019 Inspected By . SHEWIT WOLDEAREGAY <br /> E <br /> Facility Address : 1153 LINCOLN BLVD , TRACY CERS ID : 10181059 <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 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, 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 and/or <br /> imprisonment for known violations . (HSC 25191 ) <br /> Name ; Tan[ VonRuden Title : Environmental Manager <br /> Signa e : - Date: ll <br />