Laserfiche WebLink
May 04 20 , 02 : 28p p . 1 <br /> @4103 / 2019 14 : 03 2094683433 SJC EHD UNIT 3 PAGE 06 / 08 <br /> dt <br /> SAN J O A Q U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the " Nonce 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 Departrnant (EH D) address <br /> at the top of this form within 30 days of receipt of the Inspection Report HSC 254Q4 . 1 . 2(c)( 1 ) <br /> All corrections to otherviolaflons noted in the attacnea Inspection Repott (I R) or Continuation Form, or disputes to any <br /> violations, are to be submitted using thi$ certification and returned to EHD Vhin 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c) (3) <br /> Note : All EHD staff time asgociated Wth 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 tine site must include: <br /> A statement documenting what corrective actJons were taken or will be taken for each violation <br /> Copies of sample results/manifestsflydining recordslother appropriate paperwork, and/or photos verifying <br /> Corrections <br /> • t7peratars certiflcatton <br /> Inspection Date: April 02 , 2019 Inspected Sy : ZUNA BARKER <br /> Facility Address * 34243 S CHRISMAN RD, TRACY CERS ID : / 0181085 <br /> I certify under penalty of law that; <br /> 1 . I have corrected the violations specified in the inspection Report from the abov&menilonea Inspection date . <br /> 2• I nave personally examined the foiiowing documentation submitted as proof of compliance FOR EACH VIOLA710M <br /> and I believe the information to be true, accurate, and complete; <br /> photo.Q ✓plPgperwork Statement <br /> 3 . 1 am authorized to submit this rerfiric0on on behalf of the Respondent. <br /> 4 , I am aware that thine are significant penalties for submitting false information , including the pdsslbiiity of a fine <br /> andlor imprisonment for known violations. ( HSC 25191 ) <br /> Name : //ji T. S ' � � Title: fit M <br /> r � <br /> Signature: Date : <br /> F °4 <br /> APR 04 2019 <br /> i ; a �tYy DEoR rTN1 <br /> 1868 E . Hezalt4n Avenue $tPckton, Cailfornia 952051 T 209 46"4201 F 209 4CAoDI38 I vArru,sjcehd. corn <br />