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Jun 08 19,11:42a P 1 <br /> rS Q N J O A Q U I N Environmental Health Department <br /> 2018 <br /> RETURN TO COMPLIANCE (CERTIFICATION ENVEONMENTAL <br /> _MENT <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 /> 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(JR)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 resultstmanifests/training records/other appropriate paperwork, andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: April 09 2018 Inspected By: BETTY HO <br /> Facility Address: 34243 S CHRISMAN RD, TRACY CERS ID: 10181085 <br /> 1 certify under penalty of law that <br /> �1 l 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 /> 1 believe the information to be true, accurate, and complete: <br /> Photos Paperwork i.-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 and! <br /> imprisonment for known violations. (HSC 25191) <br /> Name-�r� ;✓'�AN` ? 7" S 14 SA r1/>jf 4 Tide:, <br /> Date: <br /> Signature: � �- <br />