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r , ?n S A NJ o A N Environmental Health Department <br /> i COUNTY <br /> c. , , , ._ :�,aT � rec� tncs 3covrs rv : +•:. <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 at <br /> the bottom 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 billed <br /> 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 : October 26 , 2020 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address . 2430 JOE POMBO PKWY , TRACY CERS ID : 10182265 <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 <br /> and 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 <br /> and/or imprisonment for known violations. (HSC 25191 ) <br /> Name : i 1\1 ra H Title : C,60 <br /> Signature: i .g _ Date : ( o - 2 G � <br /> i <br /> i <br /> i <br /> i <br /> C <br />