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L <br /> Sall Joaquin Count <br /> r <br /> �,r�v� ronmental Healk� Departrnent <br /> atilfornla 95205-6Z32 1ehd <br /> : 2Q9} 46B-3433 W�b � � o'� or1868 East Hazetiton AVenue. tacTerepnor�e' (209} 468-�42� Fax <br /> c, OMPLIANC CERTIFICATIONSoy <br /> URN TO RET mint be corrected w�th' � �ad� ress <br /> in the attached fnspect�on )L. <br /> Report ( EHD) <br /> ed in the " �lot�ce to COmOy" <br /> bmtitted to the Envirorimental Health Departnent <br /> 4ny <br /> MINOR. v�olatfons not ecttion Report HSC 254Q4 1 2(c)(1 ) <br /> �s ,�spectton Th,s c��t�f�catfon rtvrm f�etibsp� to any <br /> receipt ofthis of �ece�pt oat the tap of thss form w+thiri 30 days ❑r Continuation Fosrr� . or dtisputesched 1r�spectton RePort { � R) specified in the <br /> ions no in the attached ed to EHD w �thtin 3_0 lays un4�ss otherwise �p <br /> Ate corrections to ot�suhmitted using this cert+ficat+fln and return <br /> violations . are to be <br /> Inspection Report HSC 25185(c)(3) <br /> associated <br /> with failing tO comply by <br /> the above noted dates willbe <br /> Hobe : All EHD staff time �t <br /> billecl at the CU �`rehourly rate. <br /> fete , the aperato( of the s+te must Include vyolatton <br /> this certiftcatiot� to be compact�ons were taken ar wj � ! be taken fay eandlo� photos ver�fying <br /> For <br /> statement docurnenting what corsective k .A staappropriate paperwor <br /> Copies <br /> of sample resu4ts�man�festsltra�n �ng recordslothe� app P <br /> corrections <br /> certtif�cat�on Pauti Ipsooperator' s <br /> 30 . Z�21 inspected BY �lnspection Date; <br /> November10IB6995 <br /> 1916 E MARCH LN <br /> CERS { D : <br /> Facility Address: <br /> I certify under penalty of law that <br /> ' n the InspeCtionReport from r�the above - )entianed inspeGtion date <br /> 1 I have corrected the vtolatsot�s Specif�ed iV1pLATION <br /> �Ilowm documentatton submstted as proof of compliance FCR EACH <br /> 2 I have personally examined <br /> mat o to be true , accurate .. and compete <br /> and 1 be�4eve the tufa <br /> Photos <br /> ____________.Paperwork __ <br /> 3 la <br /> rn authorized to sunm4t this certification on behalf of the Respondent <br /> re significant penalt,es for submitt+ng false tinfart� attion , yncludyng the possibtiltity of a fine <br /> 4 . t am aware that these a g <br /> and/or imprisonment for knows vtotiattians (HSC 25191 ) <br /> �, ; � Tottle- <br /> CSame: <br /> Date. <br /> Signatura. �-- <br />