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�{S�1 ' lJ# kJ 1 Envi�+�nmenta) Health Department <br /> COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any_Mj6P_R_00,WDro r"Od 1r4 tbo"notice to Com pV in the atWched Inspertlon Repoff must be yror 2WO L49bu 39 4RK of <br /> receipt 0"S}rra lico. 010;cortltrcatiorl form must be Submltked to the Envlrvninentai HeaM GepWazeM{F}-} address of <br /> t#e boaam auris !npm wo wn 3o ciaYs(if roaelpt of the Inspection Report. H5 ?5OO-Z(c)(1) <br /> Aft er' L!ayi�a�ior s noted in the atka❑heci Ir+spec(lon Repan OR)or Confinuatba i-arra, or d�spuW5 to any <br /> Vidatiorrs, are to be sulirnttted using this carni Wation and retumad to F-01) f7i s fffOeS 9#1g,•0sa SPRC4e4 Jn the <br /> laspect+or RVR- HSC 25185(c)(3) <br /> Note: All IND etl#f'fime assoeiAted with failing to comply by the above noted dates Mtl be bifid <br /> at the carrent 11owly rate. <br /> For this certification to be complete, the Operator of(the ecce must include: <br /> A staternonl d❑cumenUng what correckive actlons were taken or wiff be WW for each Abrat <br /> CDpiss of sample msulWman1f6sWkre ming mv3rdsfokher apprepriafa paperwork,sadle!phobs�wify.,W c cnrro�Uons <br /> opgrraW�-ceJtliication <br /> inspection Zale: September 0% 2020 jn$pected By: NICHOLAS LOEHRER <br /> Facility Address; 166T -S Carrolton Akre, R pn r GER ID: 10142-691 <br /> 1 certify t,naer perralky of law that. <br /> i hav$c�)"ctad the vrolafipns specified?n the Inspeeffor Rapo t FJorn the abovc—menlioned date. <br /> - i haV*personairy examkmd lire fduwing dotumernkation subr itkad as proof of compliance FOR LAC H=(_ATM <br /> ? and i bE4ew the inrermabw to be trig, €rcouratu,and complete' <br /> Photos Paperwork�SLaLwenk <br /> 1 !am aathcuized to wkxni l this cerci fiction on bohnlf of The Respondent_ <br /> i 4. t am aware that"re,are signUlcatit penalties For submi(Cng(arse inh;wmation.ir1d;1lJdit The possibility of a fine <br /> andlor imprisonment for known violatlom. (HSC 2519.1 j <br /> Name-. TWe, <br /> SrrtatWre: Date' <br /> I <br /> t <br /> i <br /> s <br /> ti <br /> S <br /> 4 <br /> } <br /> I <br />