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S0 ,,-.J0 O Environmental Health Department <br /> DUN Y <br /> Greor e%.t q . hese. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in th "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This ce ification form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 da s of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations n ted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted usir g 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 iourly rate. <br /> For this certification t 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/ anifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: Augus 17, 2018 Inspected By: AARON HANG <br /> Facility Address: 950 W ELEVENTH ST, TRACY CERS ID: 10182093 <br /> 1 certify under penalty of law that: <br /> 1. 1 have corrected the violati ns specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examin d the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the informati n to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit his certification on behalf of the Respondent. <br /> 4. 1 am aware that there are ignificant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for kn wn violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> 1868 E. Hazelton Aven je I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />