Laserfiche WebLink
<r SAN,JOAOUIN Environmental Health Department <br /> °W6":—COUNTY— <br /> _�' Gre,tn...gsows here. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations notetl in the"Notice to ComdY in the aaachetl Inspection Report must be wrrec[etl within 30 days d <br /> ceipt d this inspedi,n.This certification fort,must be submitted to the Environmental Health Depanment(EHD)address at <br /> the bottom of this form wiMin 30 d,y d receipt of the Inspection Report.MSC 25404.1.2(,)(1) <br /> All wrtectl,ns to other v'olaron noted in Me attached Inspection Repon(IR)or continuation Form,or dispute,Wily <br /> Adahons,are to be submihed using the cer8fiostion and returned to EHD within 30 tlays unless othemise spadfied in Me <br /> Inspection Report.HSC 25185(,)(3) <br /> Note: All EH staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete,the,piator,the ane mustindude: <br /> A statement documenting what oonecdve actions were taken or will be taken for each vitiation <br /> Copies of sample resulta/manifestsfasining m,,rds/other app,pn,ta paperwork,and/,,photos wnfyirg corrections <br /> Opamtora os,i5,aaon <br /> Inspection Date: June 22,2020 Inspected By: STACY RIVERA <br /> Facility Address: 3304 W HAMMER LN,STOMON CERS ID: 10184253 <br /> I certify under penalty of law that <br /> 1. I have connected the violations spar:ile!in the Inspection Report from the above- rito ad inspection data. <br /> 2. 1 have personally examined the fdl,Mng documentation subriftetl as proof doomplianos FOR EACH VIOLATION <br /> and 1 believe the Insulation e,be true,accurate,and wmplete: <br /> _Photos _Paperwork X, Statement <br /> 3. I am auMonz d tosubmit Mis wr:ficuion on beh if f Me Respondent <br /> 4. 111 aware that Mere are signifioern penalties for submitting false information,induding the possibility d a fine aholor <br /> Imprisoroussaforknownvidations.(HSC25191) <br /> Name: eCA )i`HUArni5 Title: Vic'! f re5id0 tL <br /> Signsture:� �� Date: GlZv ZO <br /> 3 <br />