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i <br /> ErraV,0rc}) nr< ,&tntnot� trh 10 <br /> SAN JDA011111 <br /> RETURN TO COMPLIANCE CERTIFICATIOf j <br /> Any MINOR 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 Departmebt (EHD) address <br /> at the top 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 . HSC 25185 (c) (3) <br /> Note : All EHD staff time associated with failing to comply by the above noted date* will be <br /> billed 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 be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork , and/or photos e!rifying <br /> corrections <br /> Operator' s certification <br /> Inspection Date : Inspected Cly : WO b iGAY <br /> i • � <br /> Facility Address : Thp 1t A ZTHERS IDiN i i ITH : 13 kiNn A PlLyb , ) 180955 <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 personally examined the following documentation submitted as proof of compliance FOF 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 ) 1 <br /> Name :��,�s�u, �r . )I / I/ ! ?1ar9�r/ritle: Q <br /> Signature . A,, /i�� Date : <br /> 1@0@ € , i q;RltAn Ay nt? $ tt?I? , Alif�rr�i aia �A9 4000 I F ; t 4 -4 a + �uy�, s���hd m <br />