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i',.ir :$ <br />:H-uJ',{}*$ il l ${ <br />*l ' ;e #*rurY; <br />,.;r dirr*iii:':tiiii gtr .i?.::r!tlq.-1 i:$+ J:41 <br />Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />MINOR violations noted in the "Notic;e to Compl/ in the attached Inspection Fteport must be corrected within 30 days of <br />of this inspection. This certification form must be submitted to the Environrnental Health Department (EHD) address at <br />bottom of this form within 30 days of receipt of the lnspection Report. HSC 25404.1.2(cXl ) <br />corrections to other violations noted in the attached Inspection Report (lR) or Continuation Form, or disputes to any <br />are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br />Report. HSC 25185(c)(3) <br />All EHD staff time associated with failing to comply by the above noted dates will be billed <br />at the current hourly rate. <br />Or this CertifiCatiOn tO be COmplete, the operator of the site must inctude: <br />Astatement documenting what corrective actions were taken or will be taken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying conections <br />Operator's certifi cation <br />Date: March 09, 2020 lnspected By: PAUL NSO <br />acilityAddress: 18662 N HW'y88, LOCKEFORD OERS lD: 10182137 <br />certify under penalty of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I 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 />w <br />--Photos_Paperwork <br />\ Statement <br />I am authorized to submit this c;ertification on behalf of the Respondent. <br />[. I am aware that there are signilicant penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />€,\ata"n SCIW ri'e: Iv.rLtr .o,clet(Name: u *_ <br />Signature: