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wEnvironmental Health Department <br /> 'y_`+gs�•.�h'-y sPL'C�t�C�S'�:��C�vAi_�=.<:i�BV <br /> RETURN TO COMPLIANCE CERTIFICATION! <br /> Any MINOR violations noted In the`Notice to Comply'In the attached Inspsetion Report must be comcted "Nnr�r� 30 AM of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 2E404,1.2(c)(i) <br /> AN rjmiopg to-other vis 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 withinjQ ftM unless otherwise specified In the <br /> Inspection Report. HSC 251S5(c)(3) <br /> Nota:All EHD staff time associated with failing to comply by the above noted dates will be billed <br /> at the current hourly rate. <br /> For this certification to be Complete, the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will betaken for each violation <br /> • Copies of sample results/manifestshraining records/other appropriate paperwork,and/or photos verifying corrections <br /> • Operator'a certification <br /> Inspection Date: May 20, 2020 Inspected By: PAUL NSO ^� <br /> Facility Address: 6421 CAPITOL AVE, LOOS CERS 117:`14180605 ^ <br /> f certify under penalty of law that; <br /> 1. 1 have corrected the violations specified In the Inspection Report from the above-mentioned inspection data. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I befeve the Information to be tme,accurate,and complete: <br /> _photos_,Paperwork S`bftment <br /> 3, I am authorized to submit this certification on behalf of tba Respondent <br /> 4. I am aware that there are significant penalties for submitting false Information, Including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name:Haleh Amin Tide:Operation Manager <br /> Signature: ' r Date: 5/22/2020 <br />