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■ ■ 13 2.021 07, 00 HP Fax page 1 <br /> ■■ ■ <br /> ; J I Environmental Health Department <br /> � , z COUNTY <br /> rr t` <br /> R r � <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, HSC 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 within30 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 records/other appropriate paperwork, and/or photos verifying corrections <br /> Operators certification <br /> Inspection Date : December 06 , 2021 Inspected By : PAUL NSO <br /> Facility Address : 140 E LATHROP RD , LATHROP CERS ID : 10182153 <br /> I certify under penalty of law that : <br /> 1 , 1 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 an behalf of the Respondent. <br /> 4 , 1 am aware that there are significant penalties for submitting false information , including the possibility of a fine <br /> and/or imprisonment for known violations , ( HSC 25191 ) <br /> Name :_ 1 � j r, r Title : °���'L <br /> Signatur Date : <br /> DEC 13 2021 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> Received Time Dec , 13 , 2021 6148AM No , 7010 <br />