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EH- <br /> t SAN JOAQUIN COUNTY-' <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> NOTICE TO APPEAR <br /> DATE TIME <br /> NAME(FIRST,MIDDLE,LAST) <br /> RESIDENCE ADDRESS CITY <br /> BUSINESS ADDRESS CITY <br /> DOB SEX I HAIR EYES HEIGHT I <br /> WEIGHT I OTHER <br /> INFRACTION ❑ MISDEMEANOR SSN: <br /> VIOLATION(S) CODE DESCRIPTION <br /> 6404.5 (B) C;LC-iio employer shall j <br /> knowingly allow smoking in a wookplece, <br /> 1 <br /> ❑ FIRST OFFENSE ❑ SECOND OFFENSE Q THIRD OFFENSE <br /> LOCATION OFFENSE(S)COMMITTED <br /> Inside foci litg at bar,,4 <br /> I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT <br /> EXECUTED AT THE PLACE AND ON THE DATE SHOWN ABOVE. <br /> OFFICER: <br /> WITHOUT ADMITTING GUILT,I PROMISE TO APPEAR AT THE TIME AND PLACE CHECKED <br /> BELOW: <br /> XSIGNATURE: tailed Certified ' <br /> DATE TIME WITHIN 21 DAYS <br /> 4/12103 1:3Q, p. <br /> COURT <br /> Stockton Judicial Court Y)ept-B1 <br /> [] For the first violation,a fine of one hundred{tf 00)doffare plus state penalties. <br /> ❑ For the second violation,a fine of two hundred(5200)do#tart plus state peraltieS, <br /> ❑ For the third violation,a fine of five hundred(5500)dollars olus state penalties. <br /> EH 00 36 PHS 161(12/96) <br /> White-COURT Copy Yellow-VIOLATOR'S Copy Pink-ENVIRONMENTAL HEALTH <br />