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i <br /> San Joaquin County I <br /> Environmental Health t7epar-merit <br /> i1.tt}9 East H:+z.411jn Avrs +lue , Sircklpri C#Anvils �52G6-ti232 <br /> Telephone: (209 ) 4WO3421) Far: 1209 ) OM-1433 Web- Yy-w, Sl9ay.varEr,d <br /> I <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any hS-tt U vt:d.ations noimi in the -Nmi('.e to Ci-#1414' 111 III@ BItbrJlod Ir. spuOon Report rnu ;'. IM corrected wtnui Yj apYx of <br /> rPrnp; of this �n4pac;ron . TIAs certification form nitist be submitted to the En-tairor mental HoaArr aepariment (Etta ) address <br /> At Itw top of MI,% form within 30 days o, nfLoll 't LA Ilia inaptOur RepornL HSC 2W4 . Ujt)t 1 <br /> All y�i ►, m pl++e + vl��uUun� neted ill tho stiaehaf Inspactlor deport (IR) or tion+lrn, atlon Form , or doout" to any <br /> violat-•ons, are to be subn trim nsin l ih s cedificatirlrt anfl rrlUfncd to EI ID within N d,, unlEss a•tierwise specified in tre <br /> Inspection I,joCurt_ HSC: 751n1r ; u)(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 , v4 nprmw of the site must miuw+ <br /> A statement documentutq >`-hat e�rrPrWe actions were taken or will! be ta:<en for each vtole:ie , <br /> C.opics of tam* r"Ji talntanlloairIllraautig r000rdtfonar appropriate pa.arocrk , andla phot*; 4. I ' rng <br /> cotractions <br /> Operator's cots tcation <br /> Jant:a CDS 2416 Elane :' ansa <br /> Inspection Date: ry Inspected t3yt <br /> FacilltyAddress ; 1097 YDSLfvliltAVL CERS ID : lc1@QS61 <br /> I eor0ty under penalty of 14 AI that <br /> t 1 have coristied tho violations Apedfse in tho Irisrim, im Report ftom the nhovesmenkned ImpocGolr date . <br /> 2. 1 nave personotty exeminod th4e fertlowing documentation s%ubmitted efts nroof of compliance FOR CACIrl VIOLATION <br /> and i believT the informalion to be true, aocnimte, apd cornpie;e: <br /> photos _��'ane'.vork ��St.rlwrrent <br /> 3- 1 sill auihortzed to uut+rnit thta oe'f6oaiurl an hehalf v` the Respcmant_ <br /> 4. 1 OM aw.•ife that there are *nlfivant perlalties fRr submitting ralSe rntornlaticl, I'lldidlrig flit: porsib:lity of F fine <br /> and+or imprisonmer,tfor known votaticr .,6- (HSC, 265131 ) <br /> Name- lj1N <br /> ` [ F .t illi f` f7 Tide- L) Ile ' Y <br /> 7 <br /> Signatufe:: �< < l�C Date: <br /> I <br /> I <br /> i <br /> I <br /> w � <br />