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ivirormnental Health Department <br />Any fJIINOR 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 irr the attached Inspection Report (IR) or Continuation Farm, or disputes to any <br />violations, are to be submitted using this certification and returned to END within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />billed at the current hourly rate. <br />For this certifieatiort to be compete, 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/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />8tas{aection ®ate: Decet�tber � 6, 2024 <br />Facility Address: X010 Ht�LMAN Rid, �TOCi�T�JN <br />i certify under I�enalty of law that: <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 \/IOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos __Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 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 <br />Signai <br />Title: L�✓�,_'Y" <br />Date: _���tT9.®Z <br />