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Jul 12 21,01.44p p.1 <br /> RECEIVED <br /> {{ JUN 12 2020 <br /> {(jr�`1��� <br /> 1'� k <br /> ENVIRONMENTAL HEALTH . <br /> DEPARTMENT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M114OR violations noted in the`Notice to Comply'in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(F-HD)address at <br /> We bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other 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 In the <br /> Inspection Report. MSC 25185(c)(3) <br /> Note: All END 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 vAlt be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, andfor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: Inspected By: <br /> Facility Address: 7 -.�:ff 2�S �� �� 1 2 gStS ID: <br /> I certify under penalty of law that <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personalty examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true,accurate,and complete: <br /> Photos ;, Paperwork 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 possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name:9ANSiT.S- 5'q '4L .�� • Title: t-✓ �. <br /> -D <br /> Signature:. t �+ 'r o - ate: <br />