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=1 <br />S, NN JOAQUIN <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 within 30 days unless otherwise specified in the <br />Inspection Report. HSC 251Wc)(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/manifeststtraining records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />Inspection Date: 4 O 2— — 20 -*-0 Inspected By: 4,,.�e�- A pa--�Zo <br />Facility Address: �g� 5 _ ���.•. �= L lAjutPERS ID: !Q G /2- Y �9 t2 <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 oertification 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 />Name_ e N��c�`/.��'r Tile: <br />Signature: Date: U - /Y — 2 -e, --o <br />