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UINEnvieH De <br />RETURN TO GOMPLIAN CE d <br />Any MJNOR violations noted in the 'Notice to Comply' in the attached: inspection Repgft, must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to Phe Environmental Health Department (EHD) address <br />at the top of this form within 30.days of receipt o€the lnspection,Repor°L HSC 25404A.2,(c)(1.) <br />All corrections to other violations .noted in the attached Inspection keporf (IR) .or Continuation _Term, or disputes to.any <br />violations, are to be submitted using this cerdifrcation:and returned to EHD within'30.days unless other. ise spe6fledJn tJ?a <br />Inspection Report: HCC 25.185(c).(3) <br />Note* All EHD stafif:#irn.e gssoclsted With failing to,comply I; y the Above notes tlaxosWW be <br />billed at the c.la,rrent Dourly rate= <br />For this 66Ctiflcaii6n .to be eC3mplet�, the aperatorofthe Site must riclude <br />A statement documenting +ghat cotreofive,actions were taken. or,w lk be taken for'each: violaU.on: <br />Copies of sample, resultsfrnanifest$Araining recordslothet appropriate. paperwoirk, and/nn photos verifying <br />corrections <br />Operator's certification <br />Inspection 'bate, <br />March, t 4, 2 q. <br />Inspected By. <br />L 61 aR <br />Facility Address: <br />1,131 Fioily,ot, Trac -:C) <br />ID: <br />tC 1 i 2 .: <br />! certify under penalty of law that: <br />1, I have corrected the violationsspecified in the Inspeetlon Report from -the abfive.-mohtoned Insp'edon date: <br />2. i have personally examined the following documentation .sWnittedas probf of compliance .FOR EACH VIOLATION <br />and I believe the informationtobe true; accurate Arid complete:' <br />�E?hotos.�j%Papennrork_ Statemerrf <br />3. 1 am authorized to submit this-ceti6catiai on behalfo€the Respondent: <br />4. 1 am aware that there:are significant penalties for submOing false information; Indud.ing the possibility,of,:a fine <br />and/or imprisonment for knawn violat€ons. (HSC 25191) <br />Signature: 9 [safe: <br />1 SZ38 E, -115781€o-1 Avenue f stbo�ton Gali'Ornia i 2 5, i 20g �1. 342€:, F 2Ei9 �1-Q 13 : j �snt t a.s ce �d:cotf . <br />