Laserfiche WebLink
RETURN TO COMPLIANCE CERTIFICATION <br /> Any M!N E violations noted in the"Notice to COrnply"in the attached Inspection Report must be corrected within 34ydny5. of <br /> receipt of tl�is inspection. This certification form must be submitted to the Environmental Health Department(EHO)address <br /> at the top of this form within 30 days of reco3pt of the Inspection Report. HSC 25404,1.2(c)(1) <br /> All ccsrreoisons to othaC„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 ir) the <br /> Inspection Report. HSC 26185(c)(3) <br /> Note: All EHO staff time associated with failing to comply by the above noted dues will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site;most include: <br /> A Matement documenting what corrrjdc ve actions were taker/ or will be taker,for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certificat.iorr <br /> inspection Date: E,}! :;C ;'Flle.)er 2/ I„i);f7 1::: V <br /> Facility Address: 4101 N r'lN;::7 ,.:` Fh'�€-'C:1 <br /> ._...k:'T'.....:.. CIWRS II]; —1,) <br /> I Certify under penalty of law thit, <br /> 1. I have corrected the violations specified in the Inspection Report({Orn the above-mentioned inspC 000 date. <br /> 2. 1 have personally examined the following docurnent,0ort submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate. and complete: <br /> photos P-aperwork r„ Slalerr)ent <br /> 3. I am authorized to submit this r;ertification on bet7alf of the Respondent. <br /> 4. 1 am aware that there are significant Penalties for submitting false information, iridudinq the po-s brlity of a fine <br /> qnd/or imprisonment for known violation. (I-I;SC 25191) <br /> Narm I�.; (.c r1F7e' r+ f r: Tide: ' <br /> Signature f: (1.� 1. I' ., Date: <br /> 1868 E. Si ockton, G�F.1)IrOYI11d7 17.,._'05 � I' <br />