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<br /> RETURN TO COMPLIANC Fr,+,,ll.ltl AT nri:rs c_cS x,< i�j • 1P
<br /> '. E CERTIFICATION nou.ia. . t,,,;
<br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be '
<br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the
<br /> Environmental Flcalth,DePartment(EHD)address at the top of this,form within 351 days of rgcerpt of the
<br /> inspection report.
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<br /> All COMM-_j to othe[_Wlj#Mtuoted in the attached Inspection Report(IR)or Contmuatkp amovor \
<br /> disputes lq� oi0 are W be submitted using this certrSoehOu � ��60 days
<br /> unless otlrerwtae specified in thq�, t to
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<br /> • A statement documenting.what corrective acttons were taken or wt11 bq -an fore violation r '
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<br /> •. reCopies of samcd /other armrate apeswork, /o�jrllotos
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<br /> • ` T�s catioII'
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<br /> pection Date: Inspected By.
<br /> Facility Address: '2j i EPA ID#
<br /> I certrfy,under penalty of law that.
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<br /> 1. I have cbrrected the vidlitidiil 0. k B1a r r1J eA3 Po
<br /> inspection date "�'Ci'Tiu.$]JaSTYC
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<br /> 2 I haa`+e pgrsomlly examined the following documentatton submitted as proo o_comphancq FOR
<br /> BACH VIOTy/ TION and I believe the information to be true,sooutate,and complete: r
<br /> ,Photos ✓ Paperwork Y Stptement
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<br /> ., .:e1,. ,f 31'i5.'i ; t I. . .. . . . +It:.:: , Il 1 tLa , ,. .;•5 � r7., - , \ '
<br /> 3. I am authorized to submit this.certification on behalf of the Respondent
<br /> 4. I am aware that there are significant penalties for submitting false information,inetw1mg the
<br /> possibilityp violations. (HSC 25191) W i
<br /> of a fine and/or imprisonment for known vi ^•
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