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Environmental Health DepartmentS H N JOWIN <br /> -1 <br /> C O U 1.%1 •tip <br /> l � l <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 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date : September 05 , 2018 Inspected By : LYDIA BAKER <br /> Facility Address : 2401 MacArthur Dr, TRACY CERS ID : 10182519 <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, (HSC 25191 ) <br /> Name: f1 t t t t , ( � F �, Title : 1'1�01all-'f IL LP' Le�: ; F F <br /> l / J <br /> Signature : I{ � , i\ . !'�` Date : CI Z <br /> i <br /> I <br /> 1 <br /> i <br /> i <br /> 1 <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 I T 209 468-3420 I F 209 464 -0138 1 www. sjcehd . com <br /> I <br />