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1 <br />tJOAQUIN <br />:"..lira........... <br />Environmental Health Deportment <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Nblice'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 <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate, <br />For this certifit�ation to be complete, the operator of the site must include: <br />• A statement documenting what corrective actions were taken <br />or will be taken for each violation <br />Copies of sample results/manifests/training records/other appropriar.4 paperwork, and/or photos verifying corrections - <br />Operator's certification <br />Inspection Date: September 20, 2023 Inspected By: MICHAEL SUSZYCKI <br />Facility Address: 2�� b.r H�i�Dl�lu l�.l,\1', ST�C}�TGt� <br />I certify under penalty of law that: <br />CERS ID: 10180%7� <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date, <br />2. I 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 />toe/photos <br />Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or <br />imprisonment (or known violations, (HSC 25191) <br />Name: fY/o ha Pvt[ ri At.v.a Itr' <br />la Title: rv2 ti,,..1 <br />Signature:_ _ \/ %Iwo <br />� <br />,. / Date:-�,��,.r{ , � ? <br />