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SAH JOAQwu CouwrY <br /> EwRONmE YAL HEALTH DEPARTMENT <br /> 800 Ead Main StrwK 5'tocMm,CA 96 -3M9 <br /> TWWhm r2W)sea-M max:M 4ee.M33 wise:rNaMmMW <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any $yioletlons noted in the Now*to Complyr'in the attached Inspection Report must be <br /> c MIM within 30 days of receipt of this inspection. This oeracadon form must be submitted to the <br /> Erhvkcrnrertal Health Department{EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report <br /> All corrections to am violations robed in the attached Inspection Report OR)or Contimation Form,or <br /> dsputes to any violations, are to be submitted using thle certiticdlon and returned to EHD yfit In 30 days <br /> uniess otherwise specified In the Inspection Report. <br /> Note: All EHD staff time aseaclated with failing to cahnply by the above noted dabs will be <br /> billed at the current hourly rats. <br /> For this certification to be complete the cperaw of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample resullaftwifestaftaining recordslother appropriate paperwork,andkr owtos <br /> verifying corrections <br /> Operator's Certification <br /> Inspection Date: ZY J N E 21 , Z O t 1 Inspected By: S Ti'i Ri✓ERR <br /> 3003 NA WY oRP vE <br /> Faculty address:s-rvcx7vV. CA 95206 EPAKW. C A7Q00�t S�.3 7 <br /> 1 certly under penalty of law that: <br /> 1. 1 have corrected the vioiatlons specified In the Inspection Report from the abovoorrahtloned <br /> Inspection date. <br /> 2. 1 have personally examined the following docurnexAstlon submitted as proof of compliance FOR <br /> EACH VIOLATION and 1 believe the Intorno Pion to be true,accurate,and complete: <br /> Phobos !� Papwwork V1 SWwnert <br /> 3. 1 am authorized to submit this cer iflcadon on behalf of the Respondent. <br /> 4. 1 am aware that there ars signiflcard penalties for submitting fake WdbnrwMw,kwkx ft the <br /> possibility of a fine ardlor Imprisonment far known violations. (HSC 25191) <br /> Nares a�Pvo�'S N�/GHBo�PS ,rltle: � c®�,P. <br /> 5 urs: Date: 7,71—o D J l <br /> �orsosoorr�,do. <br />