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f <br /> S N J Q Q Q U N Environmental Health Department <br /> ! x z <br /> COUNTY - <br /> q � ,Foa*Y Greatness grows here . LNI EF(ECOOE <br /> RETURN TO COMPLIANCE CERTIFICATION SEP ' 'Z019 <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corre to th1 4a ' `6j\L <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Depar}m'e Qt' 4j. rdq•S;\AER , <br /> the bottom of this form within 30 days of receipt of the Inspection Report . HSC 25404 . 1 . 2(c) ( 1 ) lJ <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 corrections <br /> Operator' s certification <br /> Inspection Date : August 13 , 2019 Inspected By : JASON GAITAN <br /> Facility Address . 30000 KASSON RD , TRACY CERS ID : 10184295 <br /> I certify under penalty of law that : <br /> 1 . 1 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 t� 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 . ( HSC 25191 ) <br /> Name : %� li�111!,LTitle : <br /> —�� <br /> Signature : Date : C� <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-3420 F 209 464 -0138 I www . sjcehd . com <br /> f <br />