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,� _����- j.; ,. , S �1 AQUI N <br />'`� ��,� <br />��-a�,,��,;,=: Grer�tres.s,�rov�i 1rer,e. <br />�9Z9'°f� Wd8��Ol OZOZ 'ZZ'aas auiil panic°a� <br />�--;�. <br />--,nviranmental Health epartment <br />Any MINCg violations noted in the "Notice to Comply" In the attached InspEction Report must be corrected within 30 deys_ of <br />receipt of this inspection. This certification form must be submitted to th® Environmental Health Department (EHD) address at <br />the bottom of this form within 90 days of receipt of the Inspection Report- HSC 25404-1.2(c)(1) <br />All �rrection to other vi tions noted in the attachEd Inspection Report (IR) or Continuation Form, or disputes to'any <br />violations, are to be submitted using this cerflfication and returned to EHD within 30 days unless otherwise specified in the <br />Imspectlon Report. HSG 25185(c)(3) <br />,� <br />Plote: All AHD staff time associated with failing t® c®mply by the above not®d dates N�lll be <br />billed at the current hourly rate. <br />Vfib: <br />For this certification to be complete, the operator of the site must Include: <br />• A statement documenting what corrective actions were taken or wilt be Taken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />pperator's certification , <br />Inspection mate: <br />Facility Address: <br />August 05, 2020 Inspected By: <br />8129 N WEST LN, STOCKTON <br />I certify under penalty of law that: <br />CERS ID <br />CLAUDIA MURO <br />10184255 <br />1. I havE corrected the violations speclfled in the Inspection Report from the above-mentioned Inspection date. <br />2. I have personally examined the following docurnentatidn 'submitted as proof of compliance FQR EACH VIQLATION <br />and I believE the Infom�ation to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. I ant authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or <br />imprisonment fir known violations. (HSC 25191) <br />Name:_, �! �.�c�`1t��_;� �'-�::� Tide: ..�>,� •c�-..'�.--- <br />Signature:__ � ��" �'� � Date: � � ` � �-�' <br />�� <br />�.._,w.w--- <br />, �� f'" `� -'� - <br />�: <br />,� t t <br />• 1 E <br />t,s'�,`��1 t )-!Pit !Cl�,��IC.�t,,, <br />k - <br />h0/LO 3�'�d 3P!(11�3�i'��93PJ'c��1S3iVi b8588Lh60� ��Vb'£b �60 <br />-, <br />OZO�/ZZ/60 <br />