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02 / 13 / 2019 10 : 11 6182602516 PAGE 01 <br /> ■ <br /> Environmental Health Department, 0I <br /> SaP6' 4A, 1. +3e9. y, sirawri <br /> RETURN TO COMPLIANCE CERTIFICATIOM <br /> Any MINOR vlols,tions noted In the `Notices to Comply° In the attached Inspection Report must be gQlpeded witNELW OM of <br /> rBoeipt of Ws iirtspectivn • This certification form must be submitted to the Environmental Health Dapartrroot (EHD) address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report- MSC 25404 . 1 .2(cx1 ) <br /> All . rrections to other violations noted In the attached Inspection Report (IR) or Continuation Form , or disputes to any <br /> violations, are to be sulxr Wed using this certification and retumed to EHD lin 30 days unless otherwise specified in the <br /> Inspection Report NSC 25185(cx3 ) <br /> Note : All EHD staff time associated with failing to comply by the above noted dates will be <br /> bill " 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 rawlts/manifestMmining reccxds/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: _July 17 , 2019 Inspected By: ZUNA BARKER <br /> peeft Address 515 W ELEVENTH ST TRACY CERS ID: 10181209 <br /> I certify under penalty of law that: <br /> 1 . 1 have corrected the violations spedffed In the Inspection Report from the above-mentloned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true, accurate , and complete: <br /> Photos Paperwork _Statement <br /> 3. 1 am auftwized 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 /> arxVor imprisonment for known violations. (HSC 25191 ) <br /> Name: �i � !� GO c7 /� Tide : a Q 1 <br /> Signature : Date : i / <br /> AUG 13 2019 <br /> ENVIRONMENTAL MEA ' <br /> PERMIT/ SERVICES <br /> 1868 E , Hazelton Avenue I Stockton , California 95205 1 T 209 468- 3420 I F 209 464-0138 1 www, sicehd . com <br /> Received Time Au6 , 13 . 2019 10 : 10AM No , 5378 <br />