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fth Joaquin doutity. <br />.t:nv;rQn <br />enta ' I Health OepartrTent. <br />1868'East Hazelton,Avenuq, -SAoC'kton;0`a,1fqr;Ia' i962'' 22 <br />n <br />'j4 _844226,Fa -1 (2Q9) 468-3433 Web::mm&Ig <br />Telephone.- (2Q0 ;6 1 1 1 K. I gMoLq/Qhd <br />............. <br />. violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected withii <br />P inspection. This certification form must be submitted to the Environmental I Health Department (El - <br />this form Within 30 days of receipt of the Inspection Report. HSC 254 (i` <br />04.1.2Ldy <br />is to other Violations noted in the attached Inspection Report. (IR) or Continuation Form, or disputes <br />,e to be -submitted using this certification and returned to EHD within 3Q days unless otherwise speci <br />eport. HSC -25185(c)(3) <br />EHD staff 111me associated with failing to comply by the above noted dates wi <br />ad at the current hourly rate. <br />-te the 6 - tor; f the . te. ust include-. <br />cedifi.cation to be c omple pera: o sl m <br />ateMentclocumenfing what -correcfive- cti <br />a ions were taken, or will be taken for 6ach violation <br />of Sample results/manifests/training 1 records/other apropriate, <br />p paperwork,;; and/or photos verifyin! <br />actions <br />in Date: Jun -e-, 4) s-ao Inspected'LeA_rq_o <br />iddress: /000 -F7 C_hann-,V_&4- EPA ID -4 <br />,xr penalty of law that: <br />te Corrected the violations specified in: the Inspection Report from theabOve-mentioned inspection d <br />vepersonally examined the following documentation submitted as proof of compliance FOR EACH <br />I telleve the information to be true, accurate, and completer <br />S�- . tll.` Statement <br />Photos Paperwork, <br />V - L-7_ <br />i, authorized to submit this certification on behalf of the Respondent. <br />,v aware that there are -significant penalties for submitting false information, including the possibility c <br />'or imprisonment for known violations.. (HSC 25191.) <br />ure,. <br />Title: s�1s �l.C'1 <br />�1 <br />Date: <br />