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D M N <br /> A I I f I <br /> 3N <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any LiJ._LRQF <br /> i violations notod 4",illQ'U4#:E:'1 :V)comply"ill Ifle attached iTispediion RZ�pull fflust Ue 30 days of <br /> ri3c-eipt of Elis klipecfion, This certifier kin form Fmst ba SW3itfed ter qii- Hoalth Department(Ek-M <br /> Qa ;ha top of this-form vikViin 30 day5 of moo.!)t of thu,lnsporUon Re-,�Ort. HSC 26404, <br /> c1reo0onr,to vloloticg"s :Ioteiji 1p jlle aiti <br /> died lrtqmie :iur� Rc.,por! {P'}ur Fora,or dii�-;pules gcz-y <br /> YtolationF,-,-arc %u Lxst}Gras;Etei using!Iiis cerfficadci-md m.',med'm E 1 wjsNn 30 unlnr;sotell. e irl the <br /> lns�P�ctinn RePrxt HSC <br /> Nate. All EHD staff time associated with failing to counply by the above noted dates will:tie <br /> billed:at the current hourly rate. <br /> For this certification to be Complete, orihe sitewlu:3(Fq-!ufje: <br /> A sfalem.eri ducwmeriUr,p what rarrecfive 3rVnn"w�'w'; rakPJ1 or wiil t)e taf n for "riolll'ion <br /> co,ple&t4 ianlpie app--OP6iu})apuvivk, eind[ur pbolus veiirirq <br /> opem ior" <br /> Inspection Date- 0,6., '2,0 7 Inspected By: MJVAILC),�-,BA <br /> Facility Address, =<7 5 u 'Al R i R_ <br /> CERS ID: ;€: , ;;;7 <br /> I ;erNfy und�,r penaty of l,3w ttiit, <br /> 1 1 ra".e cor:recled�1.�Ie sper!f-,E1.,1 in ft;? Repc"!l firc"nl the ms?octC;Fl dale. <br /> 2 1:have persond,1,,,c..K�1.;nr`ned proof c;;compininu', FOR EACH ViOLATION <br /> Fifld I b-,iieVe Me i41rrQM1!aUCf1 M b0 tMe ',)CCUN3143j And cnripWe: <br /> phu�o,; P 0-rw 0 f 4 <br /> 3 1 tInl awilorize�'d w sl'jbrf-lit:NEN ail t1ofwEr offfia <br /> 4 1 am aware that?Dere are sigfiifi,,�wi ponalties for c;ul_imittMfalse inforrr,afion.airAuding ffie of <br /> zjndh�r irqirh,043mEmi for 251ql) <br /> a <br /> Na ri I e: Title, (11 -Tt:5c: D <br /> Signatore: Date:: <br /> Ck <br /> ._7�7 <br />