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I I <br /> Environmental Health Department <br /> RETURN TO COMPL{ANCE 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 at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404 . 1 .2(c)( 1 ) <br /> 11 <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 /> (dote : 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 corrections <br /> Operator's certification <br /> Inspection Date : March 04 , 2024 Inspected By : ' PAUL NSO <br /> Facility Address : 34243 S CHRISMAN RD , TRACY CERS ID : 10181085 <br /> I certify under penalty of law that: <br /> f�4. 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 Paperworkye Statement <br /> 3 . I am authorized to submit this certification on behalf of the Respondent. <br /> 4 . I 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 : > )1I % S r✓�'f 1-1.9_/*// L/ Title : ' X <br /> Signature : "I rwrv�4 Date : <br /> 'RECEIVED <br /> MAR 15 2024 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />