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SAN J O A Q U 1 N Environmental Health Department <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 min 30 flays 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/manifestsNaining records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />Inspection Date: 9-6.'L _ ;2 oAa Inspected By: �La-�,o 449,yzo <br />Facility Address: QD CERS ID: Y r <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 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: a C i A �� �cc �� '—I r dile: 0 A - <br />Signature Date: /Q r l y 20 __ <br />