Laserfiche WebLink
Environmental Health Department <br /> COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any Mli�Ofj violations noLad in the'Norme to C(impV in the attuchad Inapecdon Report nwsl be . u�ecLd 56+tLt r�3_0 dus.of <br /> receipt of ti}is irIBNct4on. This cerfiricatori (LKm must be sab�m!!!ed to#w F;Mmnmental Health Departrnant(EKD) address at <br /> the bottom of[his fprrii w thAn.30 data of race4A 01 The Jnspectian 1geport, HSG 25444.1-2(1)(1) <br /> AJ!gjorx cfJons tv nther viotativns;noted in file allached t nspection Report(tR)or Continuation Form, Qr disputes to any <br /> bioNtiohs, ire W be submitLed using this cartlfication alid raLurned to EH W fftiih�U W unless !q the <br /> Inspection ReporL HSG 25185 0)(3) <br /> [dote: AN EHa staff time associated wrM Ming to comply by the abovo J10ted dates will be billed <br /> at the current hourly raW. , <br /> For this cerkffication to be complete, Ma operabT(if the sb MLW irrauder: <br /> A statement dauumenting what ccrrectivQ actions were taken 4r VAIU 0e NkElrr for each VaWat <br /> Copies QF sample rec❑rWodier aqpr mate payemmk, andfor photos Verifying wrractlons <br /> Operators cerfiFtcatfon <br /> Inspection Dots; September 09, 2020 linspected By: H(GHOLAS t_Oi=HRER <br /> Facility Address: 15100 S JACK TONE RD, M ANTECA CER 1D: 10143217 <br /> car#+fy ur r pedally of Ww khat_ <br /> 1- 1 have corrected the vio%tiorrs speclfned in the Inspection Report frorn the above-mealiarrbsd lrrsRs�tJpr��aie <br /> 2. (fiave,petsunatly eYamhO tha followlnq ticoune;ntati❑n submitted as proof of compliance FOR t-AGH VIGLAT ION <br /> aM f te06 ao kbe lWrn-mbon io be true, accu+'ate,and complele� <br /> i <br /> I <br /> Hhot❑�s____'___9aperworfc Stawlller7t <br /> 3. 1 am iuk6orizod to submit ails 4�alifrcatlm on)3eW of ik}e Respondent. <br /> 4- t am aware that there ate significant penal&4 for submllting false Worme tion, fnciu ng the passtib1ty of a fur_- <br /> andlor imprlsonmenk for known violations, (HSG 251!31) <br /> Name. Title_ <br /> f <br /> ? Signature: - - - - - - - - - - - - - —Date: <br /> i <br /> i <br /> }f <br /> I <br /> i <br />