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i <br /> S A N J O A Q U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINg 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 w1hin 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All corrections to other vrolabons 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 billed <br /> 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 resullslmanifesWtralning recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operators certification <br /> Inspection Date: January 19,2024 Inspected By: KRISTINA SAETERN <br /> Facility Address: 153 E ELEVENTH ST, TRACY CERS ID: 10181331 <br /> 1 certify under penalty of law that: <br /> 1- 1 have corrected the volations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliants FOR EACH VIOLATION <br /> and I believe the information to be true,accurate,and complete: <br /> Photos 9 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 penalt#es for submitting false information,including the possibility of a fine <br /> and!or imprisonment for known violations. (HSC 25191) <br /> Name:_ ,�a w•t,r �� �Pa-cr t Title: <br /> Signature:�Y (� _Date: <br />