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i I llfi RETURN TO COMPLIANCE CERTIFICATION i 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 END 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 : L , Ell 2o`2Z Inspected By: Facility Address : 'r) C`1 e . k. c - 1 � 1 < c\ r (c , C62cto CERS ID : � 0 UZ) ! 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 ) Name : rE�1=Gvc. wc ` Title : ff ) Signature Date : - 7 ZZ