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1 ': <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. NSC 25404.1 .2(e)(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 retumed to EHD within 30 days unless otherwise specified in the <br /> j Inspection Report, NSC 25185(c) (3) <br /> i <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 results/manifestsAraining records/other appropriate paperwork, and/or photos verifying corrections <br /> • Operator's certification <br /> inspected By : lo <br /> Inspection Date: / 0 � ll " 2 / l�U�, �=Sv---,........._ <br /> Facility Address: f c� Jd6 � bi )�IN 1091A R DAALAI 4 CERS ID . 1 <br /> I certify under penalty of law that <br /> 1 . I 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. I am aware that there are significant penalties <br /> for <br /> 25f submitting false information, including the possibility of a fine <br /> and/or imprisonment for known violations. (H ) <br /> Name: <br /> Chris d/ N Title: <br /> Date : <br /> Signature: l_..r-- - <br />