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SAN JOXQUIN COW" <br />E+tWRt»+rMENTALUEnt.T14 ARAB <br />3o4 Fan Wober Meow. 3"* ter CA 952CM2.270 <br />ftphona(209) 468.3420 F= (20) 443433 Web. www a =kW <br />. 1; <br />Any bjUL02 violations noted .in the "'Notice to Comply'' in t e-4ttache d inV=60n ftPW must be <br />mrreated wift 30 days ofineipt of tlus•insp ctiwn. This rcrdfi atio n form must be submitted to the: <br />Envir*nrawtal health pent (EHD) address at the top of this fb m within 35 days of reeeipt of the <br />inspection report, <br />*1� ♦ r,j a.z r+� �r r •'�; {«r ay»��r ` rs t"' a ♦ p r a re e <br />i . . a h ., r � .: • � «• �, � r:. � � ar r t s t t� 1 M .! F rid � '- h <br />F,o.r this certification to be COMP10C. the operator of tlto Oc must include: <br />a A statcmmt doeumenting what connotive actions were Ian or will be taken for each violation <br />s Copies of sample resultslttlsrtifeststaining tewrdVotbtr Wmpriate paperwo&, dAftr photos <br />verifying corrections, <br />* 'Operator's certification <br />Inspection Date. /- .013 card y: <br />I'URity Address: l `Flo,; S. La,ve4 lr•,,/ s -9-w k, b.-.aEp s, <br />1 certify ureter penalty of law that: <br />1. I have corroded tin violations spccified in the Inspection R"rt iron} the above-mentioned <br />impe ction date. <br />2, 1. have pe morally examh%ed the following documentation submitted as proof of compliance FOR <br />. EACH VIOLATION acid 1 believe the information. to be true, accutate±, and eomplete: <br />Photos --Paperwork Statement <br />3. I-amauthto$hit.dftceaificadonoubebalfoftheRaWndenL <br />4. 1 am aware that them aro siFificant penalties for submitting false information, including the <br />possibility of a fore andtor impz sonrne n.t for knows n violations. (HSC 25191) <br />Name: C A rLL d EAJOvtse1V <br />ft-c---p-5T <br />EIM 22.02-005 Pcv 12-04 <br />Date: /-/- Zp - 2.6 13 <br />Se,146OvLIE b 409 4 7-3,2.013 <br />