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r...... ........._.... <br /> raair,iX> t � �ar`kcr( rt <br /> It# ihl +t�e�� xot.lCtaCi, alt#ot95 <br /> T010. PIP) )4�it3-3}33 t i wW.stae letiid: . <br /> RETWN Tt): C3::MMLI ME:CEI_TIFIOffIO <br /> Any-MINOR. vid7trorx> p ,i the"Natice to"' pt Y'-1h fl* tcrEd In�pecttc�r[East tt8 �orreeted witFnr;9by .of <br /> receipt of this.;ins e+vVpJ Tails certification form n lust: s 3 sttl�itii d w the I~tivir�nrr��r►#�aJ Ifieatth Dersartment.{EFip}atldr ss <br /> tale top of this fDtlti'Witt�in 30 clays of reic�►t f;tho,ICisp tlon I ep if:,HSC 25404 1.2 <br /> All corrections to other Votatiatis rioto'd in the attachcd Inspection R t (IFS°a�Gol1(in i tt��t tya Enf,or di�pt s;Ea any <br /> locations, are to be sit.ghlltted Using fillscertif ication,'and rc� tg' (-!t?:ierltFiin 30 e1aV3 rrnlsW�$l3txad;n fhs. <br /> fhpectinn Report. HSG 25�15(+r)(3) <br /> N'vte; All'E�D'OtAffift�i&at�sQCI06-d With failing to cdM f),Iy bj(:ft,Ab�irrre Jnr�ted`dat�swiN be <br /> MOO aX fi* hr�eultji`:rat .. <br /> For this-certification to be ct�t�l�rl te, the operator of t f t=61-Ini�d�. <br /> A:statementdocuinentin9.whetcoYieutitrs actions were takenor�trtlf;b fakel for aiI'vlol' ldrr, <br /> copiesof;sa►z7p(eiesttitlrriariifestsifl'ainingrecorcls/other:appiopliafepapeiriNotka.aridt+ toisverllfl�ig'':E;otzons. <br /> Insp.e,0#01t ��Jp pgtA:" �16, 2(7'l� 1. WOO B � KIN-M.,':. <br /> Faicility Addfdad::: 713 N EIaSDWDO ST S <br /> I d6ftlfV udder penalty of law the <br /> 1,.: huCArtee' gpergcoatacu � ss � h :ie, <br /> a. I''fr� parsonal{yexamina the followie g-documentation subtrr ked:'as.proof fti o-mpftance�FOPUM4 sly OI ATION <br /> 'I.;beltswthe Informationfo be true;accurate;and.complste: <br /> 'Photos. � 'Fr�per�vcrrli;:�/�fiatem�ant <br /> a.. tim atttftii>t ktd cisukrrYtil ttji ;certifRo'atidri ori'beh lf'ofttle,Resporitjl�rit; <br /> 4. I arra awaref iat there are s griScent penalties for:,submitting false information,tncludIM1.1he possibilityy,of.a.fine arid/ <br /> imprisonment.f6r-krtown e► violations. {14 C 261`.- ) <br /> 1iar <br /> ",_ vo Title: <br /> Signature; _ . 13�t`t�t- D -01 <br /> JUN 0 2 016 <br /> j <br /> i <br /> } <br />