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: . Environmental Health Department <br /> SANJOAQUIN <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M 10 Q vlolations noted In the"Idollce to Comply" In the altaoiad Inspection Report must Ni corruc6W vdik� �s_MCI <br /> reoWoF fts k cWn. This reftcallon farm must be submitted to the Envir4nmentW Health vepi�rtment(EH D)address at <br /> the bottom of this form wlthirr 30 days of raaeipt of the Inspection Repcart. HSC 26404,7,2(C)(1) <br /> Al!xr@cfions to elher violalkns.noted In the attached InspWiorl Report(IR)or C ontinuation Form, or dispu bn,4 to any <br /> violation , are to be submitted using this certtficeI.Ion and returned to EffQ WiVji_n3Qays[frTWe o0ti on&e Wacir <br /> irrspwbonReW. H3C25)851c)(3) <br /> Note: All EH staff time assoc Wed wf1h fatffing to comply by the at vre noted rata&wi1J be WIlled <br /> at the current h r)y rate, <br /> For this certification to be complete, the oparatorof the sits mu%t indUda; <br /> A statement dWumentinrg whEjf cmecGvu actrorrs were takers ar WD be taken for each 061atinn <br /> Copies of sample resu"Irnanifestsltralning mcordsfother appropriale paperwork, andfor photos verifying corrections <br /> operator's certirice4on <br /> Inspettle" Date: August 20, 2020 Inspected 13y: NICHOLAS L05FRER <br /> FacIllty Address: 18045 S KELSO RD, MOUNTA I OUSF 0 10621417 <br /> 1 Oartlfy under penalty of Iaw that. <br /> I. I have corrected the violalloris sNdfiad In the tmDpection Report from the above-menifonad inspeckion data. <br /> 2. l have personally examined the follaWing documenta#ion submitted as proof of compliance FOR F-ACH VIOLATION <br /> and I believe the informallon fo bo irua, accurafe, af1d c:onT*ta_ <br /> 1? <br /> ,YPhotf>s�PaperwoTk Statement <br /> 3. t �m authorized to submit this certification on bOalf of the Respondent, <br /> 4. I am aware that Phare are slgniftCant Penalties for submitting false tnformatian,including the passibility of a fine <br /> andfor impAconmenf for knimn vlofa6ons. (HSC 2�i?97) <br /> Name: Ti[fe; <br /> Signature' Daae' <br /> �i <br /> i <br /> i <br /> 1 <br /> fI <br /> 7 <br /> I <br />