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/ 0//V,/JD <br /> WD East Man SWK Sbcfdm.CA 95202-3029 <br /> p® <br /> T ¢y II 6 Y` e 1 468,3M Web.wwwsk0v.org1d1d <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> in j in ffie atftwhed Inspection Report mud be <br /> coffeded wftn 30 dm of meipt of this inspeckm. Thts certifim#=form niust be submitted to the <br /> Enviromienhil Haft Depaftmif(EHD)addrm at the top of fhis form within 30 days of receo of am <br /> frispectim Report HSC 25404.12(cXl) <br /> AN corredkins to other yxitations noted ire the Madied i fR)or Conhinuation FmA or <br /> disputes to any violabons,are to be submitted usft this certification and returned to E <br /> unkss otherwise spedfied in the n Report HSC 251&5(cX3) <br /> Nolp— All EHD staff tote } dd 14 <br /> FINK i certification complete"operaw ot the sitemustinclude. <br /> P A statemerd docamenOW what conechw actions were taken or will be bken for each volabon <br /> P Copies of sarriple resultshitanilbstWhankV <br /> appropriate <br /> verifying cormclions <br /> P OperaWs cerfification <br /> Inspx4ed By- <br /> FacMy <br /> ivera <br /> I cw*under penalty of law that <br /> 1_ i have corrected the VbWwns specifiedIre <br /> irispectim date. &� # t �-) <br /> 2 i have persawly examined the folowirig documeritabort subffffled as pied of conqfanw <br /> EACH i <br /> 3.. i am aWmfized to submit <br /> this ceitificafton on behaff of the ResparidenL <br /> 4. i ,kwkmft tha <br /> possdxW of a 25191) <br /> r <br /> Name:1 <br /> -7447 TdJe: <br /> x <br /> F ^� <br /> 4 <br />