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pr'..SANAQUIN <br />Any MINOf� violaifons noted in the "Notice to Comply in the attached Inspection Report must be conectsd 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(e)(1) <br />All correcir�n fp ether violations noted in the attached inspection Report (IR) or Continuation Form, or disputes to any <br />violatlons, are to be submitted using this certification and returned to EHD within 30 dabs unless otherwise specified in the <br />inspection Report. HSC 25185(c)(3) <br />Nate: 1,11 EH© staff time associated with failing to comply by the above noted dates will be <br />blilel <br />d at the current hourly rate. <br />F'ot' th1S (�erti�c�ItiOn 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: Se tember 09, 2021 �` � inspected By: _CAROL i'RBSI'O ���_� <br />i=acility AddrErss: 2375 N TRACY BLVD, TRACY �� CARS ID: 101t321Q9 �!�__ <br />I certify under penally of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection Bats. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR EACH <br />VIOI.AT'ION <br />and I believe the information to be true, accurate, andcomplete: <br />Photos V/paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I atrm aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment for known violattons. (HSC 25191} <br />Sig <br />Title: V ' ! <br />� RECEIVED <br />�o, 2021 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />