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SA N.�1 OQQ U I N Environmental Health Department <br /> OUNTY <br /> . Grrstnr;cs a�'s;,wc err;;, <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any NOR violations noted in the'Notice to Comply'in the attached tirspcetion 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 Lwections to other violations noted in the attached Inspection Report(1R)or Continuation Form, or disputes to any <br /> violations• are to be submittpd iming this certification and returned to EHD within 30 days unlet.*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/manifest&Araining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: August 07, 2019 Inspected By: NICHOLAS LOEHRER <br /> Facility Address: 1131 Holly Dr, Tracy CERS ID: 10184261 <br /> 1 certify under penalty of law that <br /> L I 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 /> Photot. I'aperwork—.4---statement <br /> 1 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: /� /'--J A/15--? Title:/a�F�f% <br /> Signature: Date: <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 4640138 1 www•sjcehd.com <br /> Received Time Sep, 4, 2019 9: 09AM No- 5441 <br />