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SAN J U A O U I N Environmental Health Department <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 /> Note : All EHD staff time associated with 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 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 : September 01 , 2021 Inspected By : CAROL PRESTO <br /> Facility Address : 507 E ELEVENTH ST , TRACY CERS ID : 10182823 <br /> I 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 1 believe the information to be true, accurate , and complete : <br /> Photos ✓ Paperwork 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 lafi ns . (HSC 25191 ) <br /> Name . G > C� 13 vi s 14 Title : A'' <br /> Signature : Date : <br /> HAR 0 1 2023 <br /> ENNVIRONINIVXFA IIca � rlI <br /> ISI? 'ARrhnIEN ] <br />