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SAN J D AH + N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnY ML42B violat;me r ow inn the"N tce to CornpLh/' in the attached I-n$Pection fie ort mu:&L be <br /> rMAO of Mr. in:%Pa ctiion, This�ertif-align form m U51 bG subrniltad to th& rnArorlmarrtsl Health aee►rt MHD} eddFessf at <br /> ZhO bnktOm of this form'wllhln �O dad,of reWIM of the lnsppm�4orti Report. H SC 254W4.h.2(C)(t) <br /> AN Z? ! akher arioJ�r1aled In Ula-Mached I nspection Report(IR)or Contirwaffan Form, pr dispurhes to my <br /> Vro018S 5- are to he submitted Using this 0erWAllan 9-nd ra[urned la EHD urtles therxdse sp ibex in lire <br /> 1rPW c M Report, H9C 251&5{c)(3 <br /> Note: All END staff time US Crated w i t4 fai f jn-g to c Orr,plY by-fie above noted dates will be Filled <br /> at the current hourly rate. <br /> For WS Ger i fcia#1 On tO be complete, the operalOr of the!Mbe must rrlcluclie; <br /> A aie-tement documenting whEll oorrecri*e acicng Were takes&will I e taken for each Miotallon <br /> Ccpies W sample re9ultWrnanifest&lrain4ng recwdslolher agpropr+ale paPervw0dr , an&w phot-aa verifying wrwkns <br /> OperaLsar's oerht`irarion <br /> In spetti on Date, AUgti Sr 20. 2020 Inspected By, PA LPL N S O <br /> Facility Address. 1229 E L OU I SE AVE, MANTECA CERAS ID. 101868 37 <br /> l oenify under pensiltyi:d Iaw that <br /> 1. 1 hawo corrw d the vtolation$spe*crFed Ir11he Irnsp49dion Report frgm the abpye-Knenlioned inspecwr7-date. <br /> 2. f-have personally examined the follornwlrrg dQcurnenrQtion submitted ae proof Of cam plMrHm FOR EAZFf VFOL TION <br /> artd f SeJiew the i+tiformakiw Lo he 1ru'9, MQUQW, and oornpfeke <br /> �Phuko k' Paper'. orlk Statement <br /> 3. I am authorized 10 eubmif this Ceftitication on beh.9lr crf the ReSPon¢erkt. <br /> 4- 1 @m aw$te 1ha1 Mer&are s3grrifiesnt D6naltiea(Or suhmillirig false Informarba F, including the pmlWliry cf aline <br /> andfor imprSunment For knaw n violat orbs. (HSC Z5 t$q <br /> Na me= A S 6�'F .� Titles <br /> 519natUre: Date_ o <br />