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Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> ,v MJlY:t,ri violrrtwnt>naif-n lithe"Notre to Comply"in the attached Inspection Report must be corrected m(dw)30 an of <br /> I", "10 Of thie inspection. This certification form must be submitted to the Environmental Health Department IEHDr addra'S8 <br /> of Ihit, (urns within 30 days of receipt of the inspection Report. HSC 254t14.1.2(cy l) <br /> t�)r,lhel vlyWQnj noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> i muted using this certification and returned to EHD within 30 days unless otherwise specified in b'^e <br /> I. 25185(c)(3) <br /> Notes: All E HU .0,Iff time associated with failing to comply by the above noted dates will be <br /> belled at Ilse current hourly rate_. <br /> i .rI I)Ii;Fjtion to be complete, thy;o,-jrrator of the site must indude: <br /> i t > rrm!n1inq wh:+t r•r,rrsoa.h✓e actions were taken or will be taken for each violation <br /> 1114,. ra• .uh../m;iwf(a,ts/tr.-ming records/other appropriate paperwork,and/or photos verifying <br /> 1101(..11i )ii <br /> Inspection I)at(r, October 25, 2017 Inspected By. BETTY HO <br /> Facility A Idicss. 5SU W Valpico Rd, Tracy CERS ID 10468777 <br /> .� rlrfy urnlnr f:.a'n;ally of law that: <br /> s <br /> 1 I have, corrrrc:led the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> I have; personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> its,i I t lis ;e the information to be true, accurate, and complete: <br /> _ _ Photos _Paperwork Statement <br /> 3 1 .=►rn authorized to submit this certification on behalf of the Respondent. <br /> 1. I aril aware; that there are significant penalties for submitting false information, including the possibility of a fine <br /> i andlor imprisonment for known violations. (HSC 25191) <br /> Title: <br /> iture. <br /> Date: °— <br /> o <br /> r7—� <br /> 0 <br /> 0 <br /> Stt�ckltu�. talifornia qr�. ''' t )09468-34201 F 209464-0138 w <br />