Laserfiche WebLink
k I N iOAQ � I N Environmental Health Department <br /> AN <br /> COUfitTY <br /> toot <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 1 Z4 <br /> Inspection Report, HSC 25185(c)(3 ) <br /> All EHD staff time associated with failing to comply by the above noted dates will be <br /> ogled at the current hourly rate . <br /> certification to be complete , the operator of the site must include : <br /> tement documenting what corrective actions were taken or will be taken for each violation <br /> G pies of sample results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : November 03 , 2021 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 620 W DR MARTIN LUTHER KING JR BLVD , S CERS ID : 10181363 <br /> I certify under penalty of law that: <br /> k <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 VPaperworkle/ ✓ Statement <br /> I- am authorized to submit this certification on behalf of the Respondent. <br /> I 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 : itti ano , Title : ltnz <br /> Signature : r ` Date : IZM � I <br /> JAN 7 <br /> t� � � M/ TESERV/ NFp � TH <br /> Cs <br />