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[[[[yyyy.••� sE Environmental Health Department <br /> JOAOUIN <br /> 1 J .1 Tri Xi 't j`: ? r? <br /> REWRISI .1.0 COMPO ANCE CERTIE1CAsn0 v <br /> Anyfly�i VOR 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 at <br /> the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404sl! 2(c)(1 ) <br /> All corrects to other violations noted in the attached Inspection Report ( IR) or Continuation f=orm, 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 ofthe 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 corrections <br /> Operator's certification <br /> Inspection Date , September 09 , 2021 r ` � inspected By : _ CAROL PRESTO <br /> Facility Address * 2375 N TRACY BLVD, TRACY CERS ID : 10182109 <br /> I 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• I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLA14ION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos ymp_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 . (MSC 25191 ) �^ ' / J� <br /> Name: r . Mjssad Title: V ' J <br /> Signature: Date: <br /> I -PIN IV ED <br /> OCT 0, 7 2021 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />