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09 2019 09, 12 HP Fax page 1 <br /> Environmental Health Department <br /> oult <br /> S AN <br /> �. <br /> x0 ;. <br /> IV <br /> RETURN TO COMPLIANCE CERTIFICATION <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 Department (EHD ) address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. NSC 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 dates 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 recordslother appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : December 09 , 2019 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 140 E LATHROP RD , LATHROP CERS ID : 10182153 <br /> 1 certify under penalty of law that-, <br /> 1 . I 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 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 and/or <br /> imprisonment for known violations . ( HSC 25191 ) <br /> 1 _ <br /> Name : J Or Title : <br /> Signatur : Date : <br /> C. <br /> DEC 11 2019 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> Received Time Dec , 11 . 2019 7155AM No , 5719 <br />