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P te{ ' SAN _ J0W1N r, 6WII MAWrwfaetalth Dep��-1h �a;-:nu <br /> . C'`L. l - ,A? � � f � C1 � liC� SS t� r0Yi5 f➢ s' ! f' , <br /> RETURN TO COMPL ANCE CERTFCAT ON <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 . 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 <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 . (NSC 25191 ) <br /> Name : �� ��, 141 Si �.j H Title : C l <br /> Signature : ( —� �� tv 't Date : f 0 - 2 6 - - � <br />