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07 / 19 / 2021 10 : 31 2097270803 JOHN PAGE 03 1 , . ; ;, �' EnvironmentalHealth Department W �k g6S `# 0Fm ` ` ria .; `�` ', re6tre� �S grow here, 1:1111 jle4, RETURN TO COMPLIANCE CERTiFICATION Any MINQR violations noted In the "Notice to Comply" in the attached Inspection Report must be corrected within 30 dW of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHO) address at the bottom of this form within 30 days of receipt of the inspection Report . HSC 25404 . 1 . 2(c)(1 ) All corn violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this oertification and returned to EHD within }(s_ unless otherwise specified in the Inspection Report, HSC 25185(c)(3) Nate : All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate. For this certification to be complete , the operator of the site must include: • A statement documenting what corrective actions were taken or will be taken for each violation Copies of sample results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections Operator's certification Inspection Date : June 25, 2021 Inspected Sy: JOHN ALANIZ Facility Address : 12862 BLOSSOM CT , LOCKEFORD CERS ID : 10185147 I certify under penalty of law that: I . I hays corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the Information to be true, accurate, and complete: Photos Paperwork _statement 3 . 1 am authorized to submit this certification on behalf of the Respondent. 4 . 1 am aware that there are significant penalties foe submitting false information , including the possibility of a fine and/or imprisonment for known violations. ( HSC 25181 ) Name : t1t � i`? Vt V` 4 -Title : uj Y) e K Signature : AaltlLot. ' Date;