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ur 12 / 07 / 2021 14 : 66 2097270803 JOHN PAGE 02 ''.. <br /> � "ww l• •• Y'464Y1'�ten. i�.i s�xLOSsaaiW//��••va ..a—•—'+TM's"'^ <br /> d IEnvironmental Health Department <br /> ,. . wu ,r <br /> to said I <br /> iL1MhWW <br /> xtI ? . � tt ,tri� rrcax atm ., <br /> 1.... <br /> RETURN TO COMPLIANCE CERTIFiCATION <br /> Any MINA violations noted in the "Notice to Comply" in the attached Inspection Report must be cor_rr�ctQ within 8 lava of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department (EiiD) address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 2W4 , 1 .2 (c)( 1 ) <br /> All 2Wins to r violar igis 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 HHD Within 30 d s 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 billed <br /> 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 resulm/manifests/training records/other appropriate paperwortct and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Cuter : June 25 , 2021 Inspected By : JOHN ALANIZ <br /> Facility Address : 12962 BLOSSOM CT, LOCKEFORD CERS ID : 10185147 <br /> Ott <br /> 1 certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentloned 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 <br /> and/or imprisonment for known violations . (HSC 25191 ) <br /> Name: aM 011161'V <br /> rla &Wj tr 1, Z . t(L aTitle: 0 Cj 0 e C <br /> Signature : Rti oo . l Date: �� - <br />