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SAN 1 DAQ U I N Environmental Health Department <br /> COLJN'i Y) <br /> �` ,}.1 411•'1 (II' jS I�1 i,4•jf 11�•I • <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 <br /> at 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(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 t0 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 resultslmanifestsltraining records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: April 02, 2019 Inspected By: LYDIA BAKER <br /> Facility Address: 3900 HOLLY DR, TRACY CERS ID: 10187607 <br /> 1 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 /> e <br /> _Photos_yPaperwork LLLStatement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that these'a significant pen les for submitting false Information, including the possibility of a fine <br /> and/or imprisonment for known lotation . (HSC�9t) <br /> Name: ; nL rn S Title: .L�i�J �v►_aA"h ore <br /> Signature: / �� ?�_—� _Date: <br /> I <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />