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SAN 10 A Q U I N Environmental Health Department <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 certlflcatlon 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 <br /> billed at the current hourly rate . <br /> For this certification to be complete , the operator of the site must Includei <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/tralning records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator' s certlflcatlon <br /> Inspection Date : October 14 , 2019 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 3250 W GRANT LINE RD , TRACY CERS ID : 10146285 <br /> I certify under penalty of law thati <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 and <br /> I believe the Information to be true, accurate , and completes <br /> Photos Paperwork Statement <br /> 3 . 1 am authorized to submit this certlflcatlon 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 : '�h� �� (' � V (- JW �j Title : AckLr \ < SA V� <br /> Signature : ZZLIell <br /> �'Z cam Date : <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464 -0138 1 www . sjcehd . com <br />