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SAN ) O A Q U I N Environmental Health Department <br /> AMENDED <br /> RETURN TO COMPLIANCE CERTIFICATIONp�l� gF�. ,e y, <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within cE E I E V <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address q <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) I✓ai� 2 U 2,u:8 <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to a IRONMENTAL <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specif�e e.DEPARTMENT <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: 2615 W GRANT LINE RD, TRACY CERS ID: 10184725 <br /> 1 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. I have personally examined the following documentation ,bmitted as proof o compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and documentation/, <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 /> w i <br /> Name: �Ct��7 Title: C '� <br /> Signature Date: 0 7 /a 5-- <br /> 4-0 <br /> k4at5 uoOL,& -PXaA-t <br /> 1868 E. Hazelton Avenue I Stockt..a, California 952051 T 209 468-3420 1 F 209464-0138 I www.sjcehd.com <br />