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N Environmental Health Department <br /> SAJOAQUIN <br /> C0 1NT <br /> RETURN TO COMPLIANCE CERTIFICA710N <br /> Any NjUQa vi❑iaGans rioted m the° fce 1v Comply'in fhs attached InapeOor) Fop❑rk must be r l 3 s of <br /> receipt of Ws frrspec�on. TW&reyifird1w form musk be submitted to khE�Er ir❑nmen%l Health Department(EHI))address of <br /> the Wtow ❑6 JNs form within 30 days of receipt of the Inspection Report. fi$G 25404-1-2(0)(1) <br /> All corrections o o�itetvi alit s_noted in the aitadhed Inspe don Report(iRI or GurWmaNan Fam,w dspulm to iiTMy <br /> VioNtlorls, are to be submiite$using this cer#fi atian and re0umeo to EHO 2tt}$+r 3 c3 us uNess blherwke specified in the <br /> lnspe0400 HSG25'i65(c)(3) <br /> {dote: Ail 6HD staff time assactata4 )Adth tailing to comply by the above hated dates will be hIlied <br /> at tha current haurryf irato. <br /> For this certff catlrcn to be complete, tt*a raWofjha-kWmusllncludk: <br /> A statement d❑cvmer+ting What o3fredive aolro bak e or Ml bo taken far aach violall❑n <br /> Cop6ps of sarnpte reoardstolher appropriate papemafk, anddor photoFa veffying�5orrections <br /> opeagge.'s exim"hw <br /> Inspection Data. August 2Q, 020 inspected By: NICHOLA LC*HRER <br /> i<actiity Address; 24371 PATTER ON PASS RD, TRACY cER in- 10144e53 <br /> l Certify under prinn4 of law chat <br /> 1. 1 have cvrre❑tcd the viaf€duns specrfiO irr 2 errs !}o++WPM Invp the Above-mentipnrid ir7sp(jcWn date, <br /> 2, 1 havo peraorially exwnined tine following WcUmentation submitted as progf of compliance FOR 1=A0Fi VOLATION <br /> r ariri I behave the inbunation to be true,aG%r$te, and cornpieta: <br /> I <br /> —_-Phgbo�; _=papenv" <br /> 3. 1 am ackiD)ized tr}submit thls geFfiflcaiion on behalf of*ie Respondent. <br /> 4. I am aware that there are slgnTficanrt penaifies for subrOf rg false irrkr malivh, Wjuriing the passibltity Df a rjni�) <br /> andlor imprisonment for kngwn araafia cros- �HSG 25191) <br /> Nary: _title: <br /> Sig�ra#r�re_ Date, <br /> i <br /> i <br /> z <br />