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�,l } I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIM NOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected wlthln 30 days of <br /> receipt of this inspectfon. This cellficatlon Form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 days of receipt of the Inspection Report. HGC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached inspection Report(1 R)or Continuation Form,or disputes to any <br /> violatlons,are to be submitted using this certiflcatlon and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHO staff time associated with falling 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 w will be taken for each violation <br /> Copies of sample resultslmanlfesisltraining records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date-, August 15, 2018 _ Inspected By: LYDIA BAKER <br /> Facility Address. 3480 NAGLEE RD, TRACY CERS ID. 10185175 <br /> I certify under penalty of law that- <br /> 1. I have corrected the vlolations specified in the Inspection Report from the above-mentioned inspectfon 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 /> —X—Photos )� Paperwork__g 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 <br /> and/or imprisonment for known violations. (HSC 25191) yr�- <br /> Name: Title; � '�$ 1�� yalaG r, <br /> Signature: Date: �J <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468.3420 1 F 209 464-0138 1 www.sjcehd.com <br />