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0 <br />SAN.P104OUIN <br />elEnvironmental <br />Heal#h Department <br />RETURN To COMPLIANCE CERTIFICATION <br />1 <br />Y M r� viol-ations noted in the "N atice to Cern plyn in the $ftatahed 1 rr.Specbon Re port mcsf be Co hed ithin Ll _ <br />receipt -ot this inspection, This oertiication fornrr rn u3t be submitbad to the Er-vjra fnen HriaEt C <br />partmerst €� address at <br />the bottom of this farm within 30 days of receipt of the lnspigq�4en Report_ FISC 2-5404-1 _2(c)(1 ) <br />Al rro ions to ether ations noted in the -attached Inspection Deport (Ifs) or nfirwathn ForM. or disputes to nnyr <br />violations, are to be submitted using tttis rertiflication and raturned to EHD within 9 da s unless atherwisu speed in the <br />InspocHon Report, HSC 26 i 8b(n)(3) <br />Note: All EHD staff fima associated with falling to comply by the above tnoted gates will be billed <br />at the current howdy rate. <br />Fo r th is Ce rtif 1ati o n to be COM p I ate r the oporatar of the site must inc[ude <br />A :StatOment documentinig what` uarreofive actions were takers or w-FIJ he in ken Ior each vioietion <br />C-00es 0 sample resulWm;anifestsArainfno records,(o her appropriate pap�mvork. arrdfor p"tes veritying aaRectons <br />operat-or's eartification <br />Inspection Date: March 16. 2021 InSpeCted By: CLAUDIA MLJRO <br />Facility Actor 11401 N MICKE GROVE PD, LORI CERS 10: 101-33249 <br />I -certify Wader penalty of law that: <br />I_ l have come ted the vJelatRons S eoifrcd in the Inspectior) Report J�orn the abov-rnentiorrr<d in:! aocaon date - <br />1 have personal y QXar road the following docUr snlatJou submitted aS pry Of of cmplianoe FOR EAG H VJGJATI ON <br />and I believe the info rmabon to be true. s, aerate, and complete; <br />�f roto —. Paperwork — latement <br />3_ f am allthOriz-od to submit this cerbficatfan on behaV of the Respondent, <br />4. l am aware that there are significant penalties for SUt)Mitting false information. irduding the panibilfty of aline <br />ancllir imprisonment fbr known Wolatons_ (HSC 2:5]$1 � <br />Name: <br />Trt.le= <br />Date: <br />j <br />