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RETURN TO COMPLIANCE CERTIFICATION <br /> Any AlMOR viotat'hn n nowd in nic"Notica in ccjrf-,viv,.i.l kispwion Repoil gust tie E_xrei;E�ir3 vr3tti as 30 cliarg of <br /> re e{pi of thK inspection. This WAGan for:ni niusf be;skibfT,itteci to the Cnmongner-ml FtenMl Depariment(EI-if`1) address <br /> at the top of;tabs term wilh:in 3'1 drys Of CE.•06 t 01 the Irzmpedan Rgjor;, HSS 23404 1.2(c 1) <br /> AN enrmction,to aMer-s;iplaRms rsoko m Me Ka&c&d insywyra Report 4FR)or Cori 0f Luaiia:i f=orm,u disputes to any <br /> }.iC7ii?3EJfia.,are ti.) be suhrr3i:Ec:ci using and rattEmad to Ef ti's specifiers in tho- <br /> 3]-Ispectier. Ropori. 113C 25185(r')t3) <br /> Note: All EHD Staff We associated with f7iling to comply by the above noted dates will be <br /> billed at the current hourly rate.. <br /> For this -certification o be complete,plete, clperator of 1!Iciud.F�: <br /> sfaternerit documcnnt4ig avliai conpciive acl3 oils were takers-Dr wi4 be take�i for cinch viol' 0i <br /> Copiin;of sample rc"Wts rn�)vlafey?s%?ria r;ifig appfQP.11j�EQ P@PertiarQtk. frT,rak;s serif�in� <br /> Ore star's cWifiGWn <br /> Inspection Date: [ks "!(M"" Inspected By: CZSPR l U Vs+.LCT'fBA <br /> Facility Address: „l f.�5 w A1 P,PU 'T ',`t;" --i< K i CERS ID: '10'8:s2" <br /> I nerltfy,un€fer penalty of faw, <br /> I. :have Corrrcied tfic sic#w'ian';spe('4 aed in Me tasW; rf nn Repod Scorn the above-inpritk3f is d in+5[)vction�i)te. <br /> 2. E have personally Citi_faftisir ng Clpcuat".grit hon sub i,:fled as pwof 4 csamMonce FOR EACH 110LATUN <br /> W 1 relieve the infwmotion tea be trum r ccawata.,and comNek <br /> P taEos ----fir prrwo Wmemont <br /> 1 ism a0ho"ed W SOMH MA C:yri:ifi+;AO on CsOMN of the Rte*po;idwit. <br /> 4. 1 am awwa that there parr signiricant p naWes for subnQUNg Ale EntoA U,l;ti;Wng t{tib poshbilifp of v Vie <br /> anwor irophsonmeni for known violirun (H;C,2510 <br /> . <br /> t y- y a <br /> I�`ic�Jr]1E; , }f''.-i�S� 5 ('. O 5� iVe: 7�r cZ�i^�\ yif l�S :Y;)•i.f7� i t S' # trc f f iT il,(s <br /> • i <br /> Signature: s # D-ate, € t r <br /> .�f <br /> �F <br /> 1868 FF F3-:-..it.: Sol",1 3 f av: -. v ..'� --...r v. .:1...�. . i ..•t!; i�S <br />