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SA610AQUIN Environmental Health Department <br /> COUNTY -- <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notce 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 c rrrrections 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 tailing 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 resultslmanifestsRraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: February 07, 2023 Inspected By: PAUL NSO <br /> Facility Address: 25775 S PATTERSON PASS RD, TRACY CERS ID: 10181249 <br /> certify under penalty of law that <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 v 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 I for known violations (HSC 25191) <br /> Name'. T o tv CIA-T-(-- Title fA A-G <br /> Signature Date: 2— <br />