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RIEGE JED <br /> SAN JOAQUIN f�pn"ntal Health Department <br /> UUNTY— <br /> W hr, ENVIRONMENTAL AMENDED <br /> - 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 <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: February 16, 2018 Inspected By: BETTY HO <br /> Facility Address: 2615W GRANT LINE RD, Tracy CERS ID: 10638757 <br /> I certify under penalty of law that: <br /> 1. 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 comp e: / <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 violations. (HSC 25191) <br /> Name: Gr/z�44 ) Title: U l J ti <br /> L-Ilignature: -- Date: © �g/lO <br /> AOR 1 <br /> X,0 Gl d 0'i(\ —tvv 1�� ( n . <br /> Y42)E� cca VSA P , . 0 n-M 4� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 09 F 209464 0138 1 www.sleehd.com <br />