Laserfiche WebLink
DonuSignEnvelope ID:3A636DBB'EO844D33-8o48*73Fn44AAA1F <br /> ' <br /> �A N - OA ° N | N Environmental Health Department <br /> '-- COU[4IY <br /> g/.� hv*� <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 ofthis inspection. This certification form must besubmitted tothe Environmental Health Department(EHD)address at <br /> the bottom ofthis form within 30days ofreceipt ofthe Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Fonn, ordisputes tu any <br /> vio|ationu, are tobosubmitted using this certification and returned to EVD within 3U0 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Nota: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the currant hourly rate. <br /> For this C2rfifiC8fiOO to be cOD1O|8f8. the operator ofthe 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 popomvork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 20 2018 Inspected By: JA8{}NGA|TAN <br /> Facility Address: 148UOVVSCHULTERD, TRACY CERS |D: 10181028 <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. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the information to be true, accurate, and complete: <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 and/or <br /> imprisonment for known violations. (HSC25191) <br /> Name: Title: <br /> Signature: —Date: <br /> 1868 E. Hazelton Avenue I Stnoktun, California 95205 1 T 208468-34201 F 209 464-0138 1 vmww.sjoehd.00m <br />