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f .r F ' { 3NI ;` vi, 3 . ,. . �' ..a �. . N. vg„��q 9re y g _ f d iS4FF . 3 .° `` y 1 INN Any MINOR violations noted in the, " Notice to Comply " in the attached Inspection Report must be corrected within 30 days of receipt of this inspection . This certification fornii must be subrnitted to the Environmental Health Department ( EHD ) address at the top of this form within 30 days of receipt of the Inspection Report- HSC 25404 . 1 . 2 (c) ( 1 ) All corrections to other violations noted in the attached Inspection Report ( IR ) or Continuation Form , or disputes to any violations , are to be submitted using this certification and returned to EHD within 30 days unless othemlise specified in the Inspection Report . FISC 25135 ( c)(3 ) Note : All EHD staff time associated with failing to cornply by t € ie above noted dates will be billed at the cssrrent fsOttrly rate . or this certification to be complete , the operator of the sitemustinclude A statement document ng what corrective actions were taken or will be taken for each violation Copies of sample results/manifests/training records/other appropriate papenrdork , and/or photos verifying corrections Operators certification 111spection Date : N1alcfr ; u � i1 , > -- InsPected By . yacs0 "sty Address : 2 < 4 _ NI rlVi! , _ I certify under penalty of law that 1 I have corrected the violations specified in the Inspection Report from the above - inentioned inspection date . 2 4 have personally examined line fdllovvtng docun-tentation suhmMed as proof of compliance FOR EACH VIOLATION and I believe the information to be true , accurate , and complete - Photos Paperr✓orl: Statement 3 1 am authorized to submit this certification on behalf of the Respondent. 4 , i am aware that there are significant penalties for submitting false information , including the possibility of a Ilk and/or imprisonment for known violations . ( HSC 25101 ) INN In e : Iritle : _ ` � I C Signature : �� - V �' � h� C,- ; L,: C� a % e : i Y . .. J : C. . .r.' .; j i NCS' tFi 3f-� c „ �Ve . � , .,_ dt� '! r;