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• • RECEIVED <br /> / SAti,}ppQU1N CouN'n' <br /> r EtMWNtdFNraL HEALTH DEPAR7MExT <br /> 600 East Thain Steel sloddonI C° ss2o2�ozs . FEB 2 7 2012 <br /> rd,,phl":(209)468.3420 Faz:(209)46&3433 well: 1N1N SIOW <br /> H€`ALlli <br /> PERMIT/SERVICES <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> prry Mt OR violations noted rn the��to Comply'in the attached Inspection Report must be <br /> of this i ction• This certification form imust dof receipbmitted t Ole <br /> 30 ds of receipt t the <br /> rzvrected within address at the top of this form within <br /> Environmental Health pepartment(EHD) <br /> Inspector?Report. HSC 25404.1.2 cx1) Ins n Rept(lR)a lime' ation Form,or <br /> AI!comechons to other vrolafions naaaaeeoo m the attached Pacfic . <br /> disputes any Mons.are to he subrmtted using this certification and returned to EI ID wrlhm 39—Y§ <br /> unless otherwiseated Reprt HSG 25985(c}(3} <br /> s rrt the Inspectionfailing t0 cantPlY by the above noted dates will be <br /> Note: 11 EHD s3aff time t <br /> billed at the current hourly rate. <br /> For this certification t0 be t:am t en wwai bbeet�n�include.each lation <br /> . A statement documenting what e * to paperwoM and/or photos <br /> • Copies of sample resutlOrnantfesls/trainmg recOrds/other appropris <br /> veWng <br /> . ra;t00es certification <br /> rFac7j.Ijty <br /> on Date:February 24, 2012 Inspected By-.Gar-ret Backus <br /> AddresS:4 � Pershing AveEPAIDeCAL000317229 certify under penalty of law that= <br /> 1. I have corrected the violations spent-led in the Inspection Report from the above-rtren6oned <br /> inspection date. <br /> 2. I have personally examined the following domunOrd�rr submitted as proof of compliance FOR <br /> EACH VIOLATION and <br /> 1 believe the intorrnatron to be true,acarrat%and comPlSte: <br /> Photos__Y —Pat enwTk Smtement <br /> 3. t am authorized to submit this certfficaforr on behalf of the Respondent <br /> 4_ 1 am aware that there are signM ant penalties for submitting false information,ir>cluding the <br /> possibility of a fine andforkrpisonmentforknown violations. (HSC25191) <br /> Title:��9x----- <br /> Name: di <br /> $Ignature: <br /> Date. o <br /> Eno 22m-ws r:"09111 <br />