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SAid 40AO�N COWM <br />EwiRowENTAL HEALTF+ DEpARTMENT: <br />600 East Main Street, Stodftn, CA 95202-3029 <br />TWWhow: (209) 468-3420 Far (209) 468-3433. Web:gLehd <br />RETURN TO CG• <br />,MPLIANCE CERTIFICATION, <br />Any MINOR violations notedJ9 the allotice to Complym in the attached -inspection -Report must be <br />corrected within 30 days of receipt of this inspection. This ceriffication form must be subn2ided to the <br />Health Department (EHD). address at the top of this form within 30 days of receipt of the- <br />fnsirieectlofi Reo6rt. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Conitinuation Form, or <br />disput6s:;o any violations, 'are to be submitted using this certification and returned to EHD within 30 da-ys <br />unless Otherwise specified in the Inspection Report. <br />Note: Al I EHID. sinfitime associj*d wit li failin to ' rnpi 0 b a•ove <br />co♦y by th nol6d dates will be <br />bill6d at tI* cur -rent hourly rate. - -7 <br />For this cercation to be co'mpletetheoperator of thesite m 1' <br />ust nclude: <br />A statement documenting whatcorrective-actions were taken or v'All.-be taken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork,'andfor photos <br />verifying corrections <br />7 <br />Inspection Date: C, Inspected !3y -.- <br />Facility Addmss:—t &AKQox EPA: iD#: <br />'I cerWY under penalty -of law that. <br />I - I have corrected the violations specified in the Inspection Report from the a'bove-mentioned <br />inspection date. <br />E. I have personally examined the following documentation submitted aS'proof of compliance FOR <br />EACH VIOLATION and I believe the information10 be true, accurate, and complete: <br />Photos aperwork kl,;tatement <br />3. lam authorized to submit this certification on behalf of the Responr- <br />( i <br />e <br />-Signature: Date- ell! <br />Acl <br />810/ Z00*d 000Z# LO:tO 9002/TZ/80 <br />