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SAMoJOAQUIN <br /> Environmental Health Department <br /> r; C_QUNT1 <br /> RETURN TO GOMPLIANCE CERTIFICATION <br /> Anw MINOR violations noted in the`Naiiae-a Corgvv'in IPrC altarhpd I zspec ion Repar muat be of <br /> receipt or h s ihsperG4n. T-is oertlficadan four must he submitled to.he EnvirmrivnLui HP01th Llepartment?EFd}address:a- <br /> the bot•.om of t.s form within 30 days of roeaipt 0`the 1,L%p-orlon Repot HSG 2540e.1.2fo)(1) <br /> All correations ba QJW_vi�nowd in IIIc atr@chm InRpeemn Report(IR)o-Conlinusiian Farm,or disp',2Ies R3 Jnr <br /> violations,are to be submitted using thA ca-ti9cation aid returned b AD tv01-111 311 days um.-ss oto-.envise apeci:iea it In(: <br /> Inso9e.iun Repor.. I'ISC 25185(rl(3) <br /> Now All EHD staff firm associated with failing to rgrraply by the above noted datass will be billed <br /> at the current hourly roti. <br /> For this cert€fitlation to be Complete, theoperworof the ante mustinrlude <br /> A sWteme d documeniing what m-r$ciive adions were tsian arxvillau iakcn Ful eaCtt V101111on <br /> Copies o{aampic wlt3 l tnlfesls'Ualydrg rertxasrnther appropria?e paperr.+ark.anSor Photos vurfyintl GOITer:tlams <br /> Operaiara certification <br /> Inspecilon Date; January 04, 2022 Inspected By: GABRIELA GARC:IA-MEJIA <br /> FacilityAddross: 5777 8 FRENCH CAMPRI).STOCKTON CERS ID- 10182157 <br /> I aertlfy under oenshy of law-hal: <br /> 1. I have cam vied the vioIatiuns spcc:ifiud in Ih0 tfjsprrtir)r,Rppoft from the above-mentioned insoeation date. <br /> 2. 1 have paraonsgy axsminec'ha fai�xwr:rrg do:-unantation sut:ni:tod as Proof Or Compliance FOR EACH VICLA71ON <br /> and I hclieve the Inrormatiom rp pe L'Wp,aroUratp,and complete: <br /> ___phnlos Paperwork .Stammeni <br /> 3. 1 am authorized tc submit chis ccrlificator~on benalr of the Respandert. <br /> 4. 1 am aware hatthere are eignifioad-t penalties for subrniStrrg tdlse inr4lmatrplr.InrlurlF 1he ponaibilrN of a fine <br /> .�inrlIir IinxIgo nment fnr knawn kgdaha-Is. (HSC 2519'j <br /> I <br /> hiamr;= F Title. _ <br /> Date: <br /> Signature= l a } <br />