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S4 J O a O U I N Environmental Health Department RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection . This certification form must be submitted to the Environmental Health Department (EHD ) address at the bottom of this form within 30 days of receipt of the Inspection Report . HSC 25404 . 1 . 2(c)( 1 ) All corrections to other violations noted In the attached Inspection Report ( IR ) or Continuation Form , or disputes to any violations , are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report, HSC 25185 (c) (3 ) Note : 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 : Inspected By : Facility Address : CERS ID : liiiiiiME I certify under penalty of law that: 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date . 2 . I 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 for submitting false information , including the possibility of a fine and/or imprisonment for known violations . (HSC 25191 ) Title :Q ) ,W � L Name : � � i Signature : Date : � i `� 1- Z