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Ennrcnmerdal Heallh Department <br /> 1al East Haraton Avenue. Stprinnrl.CaliSoma 952C5{{23S <br /> TMophi—e_12091488 3424 Fox_120s1689-3433 "a J agarr 01116frd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR wioliikns noted in Ihe'Notioe to CompV in the attodmed lespection Report must be ountr ed a'Wn 30 dated <br /> receipt of this inapecuon. Trill ceniNppan Ido must se stmrnni to me Emvironmenul Health Oepanman!(EHO)address: <br /> m0top of Mlaram'wiMi�30 days efreceipt pf eye lnspectieo Regan HSC254p412(cH11 <br /> vilyisl are bX submitted <br /> id a iMIMI In1Ta certification <br /> and <br /> to EH IIH)or t'A days unless <br /> FIXm,ar isePspa many <br /> llrsdo are tp be submltted using thin certigcetion and returned to EHO wilh'n]O tlevs unless otherwise speciAed m the <br /> Inapecdon Report. HSC T51851aHS1 <br /> Nota:All EHD staff tame asenciated with failing to comply by the above noted dates will he hiller <br /> at the current hourly rata. <br /> For this certification to be complete, theoplausa fMe aim musbnclude <br /> A slamment documenting what r Mrihxe apliane were token or will to talren for each wglat" <br /> Copies of sample resul"arrifaelsttraining recordslother appropriate paperwl alwNor phoms verilylrg warectione <br /> Cperaior's certification <br /> Inspection Dale: Nove'nter 21,2079 Inspected By: Casa'Reralcaea <br /> Facility Address: 143111 s RORFRTS RIC CERS Io: 101>3 W <br /> I oerVy under penalty of law that ' <br /> I I have corrected the violations specmetl in the Inspection Repos From the aboveanentioned inspection date. <br /> 2_ !have perconalty t ammed the following docurritoo on submlded as proof of oo"ionee FOR EACH iACLATICN t <br /> I believe the information to be true.accurate.and compilers <br /> _Photos�Fapareel Statement <br /> 3 lam aumoraed to mit this certification on behalf ofthe Respondent. <br /> 4. I am aware Ip4t Mere ar significant penalties kr wbmitting false information,indudmg the possibility ofa fine awift <br /> impritimmeAtforimi violations. (HSC25191p <br /> Name. Title: <br /> 1 <br />