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fit <br /> All, <br /> t 51 � � Int is <br /> �ff} t <br /> j • 1 t1 ! a <br /> SAN J D AH I N Environmental Health Department <br /> � r <br /> RETURN T4 COMPLIANCE CERTIFICATION <br /> AftYt�I '408- vio 1c }6 need in the '1Nglize ;u Contpt-f 'ur $n otta•_hed I-sperhori Hzaort must ne catreatv7l !W rr r 3U d_Y� or <br /> rac++fpt vrih ` a tnsPecGar Ihis riamir,catiar, !arm 111u6l by tt,;bmi%W In rho Erwilor+ rrwnto tdetaro Dapaininnl (LHaj p,ln, rtid <br /> ar the tow, of Ihill luiM wtlttln 3n days of tercelpt kit the Insoec1on Report. 1.1�S; 2544i. 1 . 2tch 1 ! <br /> A ! r2ftS'-'l U :s to oU,efyielAbcns ncded in ing aLaeherl IrsQectan Report {!R} or Caplin lloh Form, tar clftPwtss fo any <br /> YtOgllms. are to ho tubtrtltod ueirq this rnrlifi elle + tarp rultirnea to EhD w ad day unlosr rr1►terwlsg s1m ied in she <br /> Inspaction RcWft HSC 25185(cl?. 3j <br /> Note : All EHD stait time associated with failing to comply by the above ncted dates will be <br /> billed at the current hourly rite . <br /> For this certification to be complete , Che cparetxafthssilur, taifraude . <br /> A sla,lurrvnl Ovumemgng + im? i,in t Ivit 4o .,t om weNd taken or wo P bo ialu+ n W each YkilA 9n <br /> Grr„ies of sarripte resultsrrnsnifesiv aInirg recordelothet arPniPda*L% paperwwi andlor W-`ribs Wil' 1r g <br /> rurrrtpllp+l5 <br /> quc a!rx'5 curtinratk,n <br /> Inspection Date : Decembe - -: r1r zu18 Inspected By : de&UNA SAHKER <br /> Facility Address: 1G9:r YO El'AF 1- A :' E, E:ar:N '. .'Jtl _ CERS iD . , 0180561 <br /> I Dertiry unser pct-jalty of Isw '.haL <br /> 7 t Ibve cart or [hs vint�lrorrs ;,�tacttied in the Inspecle�, NetLcr frMl' Ire abovbotnarn'.loned imo -, liars dela <br /> I have p,ersomOly exatimned tr" tolla'aing docurc•t;ut�.,n 6ubnthtcd et plont of oomEilsBnGv 1- 4 . ' `- t' VI <br /> Ani I ba!I.+$'1F. In" lr ernat..on to bo Iac�arn?e and rnrti�,Fbie' <br /> r' <br /> Pho" _ - —Paperwork l ` 31:demen! <br /> 3 I em .tu hgrtzeC tc sutrR•1 ttr� ciertfir Wn ori hehal` or Itle Respornlen - <br /> { 1 arcm an-are t".at it:ere are sir�r: 'tcent prtut:a.: 1�' sutxr'Yt,tx3 'alss inion ; : Jen , .h,dirog t_he passik:6i} el <br /> ar+dlar t,»prlaanntent fc< intyA,rr violations . 11180 251 `311 <br /> l� <br /> 11-1w6if�F _Data: <br /> Signature -_ = <br /> ti 't•�� �1 ' �11 1` t � ` i� ��{ �� �tii � lt la �' �� <br />