Laserfiche WebLink
Received <br />1/26/2023 <br />Environmental Health Department <br />.� SAN-JOAQUIN <br />u N r Y <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice 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 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 />Dote: All EHD staff time associated with failing to comply by the above noted dates will be billed <br />at the current hourly rate. <br />For this certification to he 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/manifestsltraining records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />Inspection Date <br />Facility Address: <br />January 19, 2023 Inspected By: <br />1975 W LOWELL AVE, TRACY <br />I certify under penalty of law that: <br />A -41M1] <br />SHEWIT WOLDEAREGAY <br />10181579 <br />1. 1 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 <br />and/or imprisonment for known violations, (HSC 25191) <br />Name: `A n. Title: 45s0 C{2�)�p�rt�th4i°IrTA''u�//. <br />Signature: —rDate: 1,�Ol <br />