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r - <br /> Environmental Health Depalrtmerat <br /> SAN N <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M I NOR ViOI iOMO noted in thb'Notice to Comply"in the SJW ohed Inspection Rnf}nrt must be of <br /> receipt of this Inspection- 'htr�certifinkcI form mtjIg be suh nitked to the Envin)nmonw HeEjCLh t>eprartment(CHO)M&OSs Ot <br /> the!bottom of this form within 30 days of receipt of 1he Inspection Re Port- HSC 25404-1.2(C)(1) <br /> AI corMctlons to other violations noted In the attached tnspmt nri Report(IR)pr Continuatlan Farm.or disputes trx any <br /> vlolatlons,ara Co ba submitted using this carlificatlon and returned to END with to 3f}.days unless Gthelwls8 specIrled in the <br /> Inspection Reporl- HSC 251MC)(3) <br /> Nate: All EHD staff tarne associated with failing to comply by the above noted dat0S wilt be <br /> billed at the Cur-rent dourly rate. <br /> For this certification to be comp)ete, the operator of the site must include, <br /> A slalement documenting wlldt WrreCtiVe aetionS W?M taken or will be taken for aach violation <br /> Copies of sample resul Wm-an ifealsllraining recordslother appropriate 1xaporw".andlor photos verifying correcliWs <br /> QperaCor-s certi19C31iiors <br /> lrlspectiar� Dot+?: � Inspected By: i _ <br /> Facility Address: . IS ,JP4l.{ CERS 1D, <br /> I certify under penalty of law thal; <br /> 1. l h@ve correrled the violations specified in Me Inspection Report from the abov"entioned inspection date. <br /> 2- 1 have p.Br5aaally examined the faliow+ng docurnentatlon submitted 28 proof of compliance FOR FACH VIOLATION <br /> and 1 b21leve the infermatlon tv be true,accurate,and complete; <br /> Photos Paperwork_Statern:ent <br /> 3. 1 am authorized to SLjbrrrlt this CertificaUvn on Uehalf of the Respondent- <br /> 4. 1 am aware that there are significant panaftles for submitting false information.including the possibil�ty of a fine anWar l <br /> Imprisonment fQr k�n`own violations. (HSC 25191) <br /> Name: <br /> Signature. bate: 1 D/ J-�� <br /> - , 19r-jr, PY I r YP <br /> �� ojl � � . <br />