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�..,�... . � � i ► • ''♦ _ t' t. f • . f.. •� • is y Y f : #-. <br /> c • .� f - • ♦I w • is - ► • - � .. .,r # ♦:.. � �•:♦: � • •.: • #. <br /> i F 3 <br /> Of <br /> Inspection �P rInspected ftl�k4ue- A l <br /> under9 Sr 1749 <br /> I certify penalty of <br /> 1. I have corrected the violdtions specified in the Inspection Report from the above-mentioned <br /> inspection date, <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete; <br /> Photos Paperwork—1 —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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: <br /> Signature: r <br /> �r — <br />