Laserfiche WebLink
JAGK'S TRANSMISSION REP. 209-823-3058 <br />p.l <br />AN I AQ U I N Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MIIJM <br />�2I violations noted in <br />tits "Notic e to Corttply" <br />in the attached Inspection Report <br />must br.. cormcir d within <br />301day n of <br />receipt of this inspection. This <br />certification form must be submit#cd to the Environmental <br />Health Department (EHD) address at <br />flip, bottom of this form within 30 <br />days of receipt of the <br />Inspection Report. HSC 25404.1.2(e)(1) <br />Ali correCtionS t0 otheryigl8tipns nn(ed in the attached InSppGtipn Rnpprt (IR) or Continuation Form, or disputes to any <br />violations, aro to bo submitted using this cortiticntion and returned to EHD within 30 days unless otherwise specified in the <br />irinpoction Roport. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted d�tcs will h+r <br />billed at the current hearty rate. <br />dor this certificafiion fie be etampiete, the operator pf the site must include: <br />A statement documenting what corrective cations were taken or will be taken for each violation <br />Copus of sample results/manifests/training rerordslother appropriate paperwork, and/or photon, vorifying corroctions <br />Operator's certification <br />Inspection Det+, <br />t=acility Address: <br />certify <br />March 07, 2(722 Inspected �y: PAUL NSQ <br />276 MQFFAT BLVC7, MANTE�A <br />i <br />under penalty of law that: <br />CERS ID: 'IO'18567� <br />1. I have corroded the violations specified in the Inspection Report from the above-1tlelttipnt?d inspoctipn datp, <br />7. I have personalty examined the following documentation submitted as proof of compliance <br />FOR EACH VIOLATIOiJ <br />and I believe the information t4 he true, iccurate. and complete; <br />_ Photos _Paperwork Statement <br />3. I am au#hprized to .^,ubmit this cortiiication <br />on behalf of the Respondent. <br />4. i 3m aware that there are significant ppnalkips for submitt <br />ing false information, including tha possibility at a true <br />and/or imprisomnnnt fpr knewn violation ,. (HSC 25191 } <br />Name: K � If jw''� Title: <br />Signature: <br />MAR 10 2022 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />