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SAN J OAQ U I N Environmental Health Department <br />COUNTY <br />Grectness ar —5 b, r <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 <br />at the top 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 <br />corrections <br />Operator's certification <br />Inspection Date <br />Facility Address: <br />July 05, 2018 Inspected By: <br />LYDIA BAKER <br />23623 S BIRD RD, TRACY CERS ID: 10187255 <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 I believe the information to be true, accurate, and complete: <br />_Photos � C 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 violations. (HSC 25191) <br />Name: A 17 /i w O U D Title: C_Q V I rNE t? Cy Q i,jjew <br />Date: '71,S61,x$ <br />1868 E Hazelton Avenue I Stockton California 95205 i T 209 465-3420 1 F 209 464-0138 1 www slcehd com <br />