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SAN4J OAOU IN <br /> Environmental Health Department <br /> COUNTY <br /> +. aJ` t? :si =' rSi ';} F1, Y. i 'i"• � t? <br /> MUM 100 COMPLIANCE CERTIFICp►'fm <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 at <br /> the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404. 1 .2 (c)(1 ) <br /> All correc i ,g_ 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 EMD 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 (derrifcation 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 corrections <br /> Operator's certification <br /> Inspection Date , September 09 , 2021 inspected By : _ CAROL PRESTO <br /> Facility Address , 2375 N TRACY BLVD, TRACY CERS ID : 10182109 <br /> I certify under penally 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 /> .Photosymp_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 ) � / <br /> Name:. 7'i#le: V ' <br /> Signature:_ Al Date: X01 �1 _ <br /> a R E <br /> GEIVELJ <br /> OCT 0, 7 2021 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />