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Environmental Health Department <br /> Ni T Y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any I•,>1L�ILPB violations noted in the."Nuticc to Gomp,y"in the attached ln8pectlon Report::rust be corrected within 3C!des caf <br /> rectiPt of tr is inspection. This certification form must be submitted to the Environmental Health DOpartment(EHD)address at <br /> the bottom of this form within 3g days of receipt of the Inspectlon Report, HSG 25404.1.2(e)(1) <br /> All carrecticrns to other violations noted l,j the attached Inspection Report(IR)or Qontinuation Form,or disputes to any <br /> violations,are to be Submitted using this eertificatiorj and returned to ENt? t�€thin 3fl days unless ofillerwise specified in the <br /> Inspection Report. NSC 25155{c)(3; <br /> Note: All EHD staff time assaclaled with failing to Comply by the above noted dates will be killed <br /> at the current hourly rate. <br /> For this certification to be Complete, the Operator of the site must Indude: <br /> A staterriersi corrective actions were taken or will.be taken for each violaticr <br /> copies Of sampla resu':ts.='manilas s/training record,;:other appropriate paperwork,.and/or photos verifying corm4AOns <br /> Operator's cortitication <br /> Inspection Date, — October T-5, 2020 � Inspected sy„ JOHN ALANIZ <br /> Facility Address: 795 E ROTH RD, FRENCH CAMP GERS ID: <br /> i certifv under permity of law that � _�--.•...... e-..... w __ <br /> I have corrected the violations speciTled in the Inspection Report from the above-frenticLqed inspection date, <br /> ?. !have persOnaily examined the 1;ojlewing drrcurneniaVonsubmifted as proof of compliance FCi,EACH VIOLATION <br /> ION �{ <br /> and I believe the information to he true, accurate,and eor ip;ete: <br /> 3. t arm authorized to submit this certification on behalf of the Respondent. <br /> 4_ 1 am aware that there.are significant pen Oes for 5ubrnitting Nise inforrnadon,indudbg the posdbiRY Of a fine <br /> andlor irnprisonrnenl for known vrofaticrs. (NSC 51�1) <br /> l���rne; � � <br />