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9ZH 'ON W 'S V1 I H -L -Jac ;Wli P;Al ;);y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the 'Notice to Comply' in the attached Jnspection Report must be corrected within 3D days of <br /> receipt of this inspection- This certification form must be submitted to the Environmental Health Department(EHD) address; <br /> the top of this form within W days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) . <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken far each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: <br /> U f. <br /> Inspected By; C, <br /> Facility Address: GERS ID: *10`3 G'20 <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 Paperwork Statement <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 /> and/or imprisonment for known violations. (HSC 251191) <br /> Name: icle'l-I 0 Icl 1 7 _Title:_ )7 �.t✓ <br /> Sicinature: <br /> Date: -9V 7- kAl <br /> RECEIVED <br /> FEB 08 2^,O <br /> ENVIRONMENTAL 111FALI'll <br /> 1)1:PA RTN 11:1 N'I' <br /> P90S-d717-5 <br /> I,-d dq 1,:90 9 1, Zo q. <br />