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• e� �Z/i8/2c>u� Department <br /> �nvi r <br /> ®nmental health Dep <br /> sw MUM <br /> o <br /> RIETURN To cin <br /> PLIANCF C� N <br /> RT1FlCATIO <br /> attached inspection Report must be corrected Wlthli�30address at <br /> in the Department(EHD) <br /> Any_M NOR violations noted in the"Notice to Comof <br /> ply" 1 2 c 1 <br /> receipt of this inspects <br /> on• This certification form must be submittedeoae HSG 25404tai ( )(it) ep <br /> the bottom of this form within 3Q days of receipt of the Inspection p rt IR or Continuation Form, or disputes to any <br /> ion and returned to EHD within <br /> All corrections to other vioiations noted in the attached Inspectiounless 0[heIWI5E Specified in the <br /> n Repo <br /> violations, are to be submitted using this cerci#icat <br /> inspection Report. HSG 25185(0)(3) <br /> Note: All EHD staff time associated with failing to comp�Y by the above noted dates will b2 <br /> Milled at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> tion <br /> A statement documenting what corrective 9Ct1011s were taken w+a1 pope r°keand/ololpahotos verifying corrections <br /> Copies of sample results/manifests/training records/other appropriate <br /> • Operator's certification <br /> Ins acted By: PAUL N50 <br /> Inspection Date. November 19, 2020 p <br /> Facility Address: 1916 E MARCH LN, STOCKTON CERS ID: 10186995 <br /> certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the inspection Report from the above-mentioned inspection date. <br /> 2_ 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos ,.r. PoVvr-work Sfafemen} <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4_ 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br /> andior imprisonment for known violations. (HSC 25191) <br /> Name: i �� UIL...,._. Title: �ACq <br /> Signature: 4— <br /> Date: <br />