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S A N J 0 A Q U I N Environmental Health Department <br /> (-OUNTY <br /> F., 6 !'f){of•y'-. off•:v. <'I r., <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR 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 correctlons to other violations noted 1n 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 £HD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, 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 resuitslmanifests/training recordslother appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: V ��y rap ogo.P 5 Inspected By: <br /> Facility Address: Ze,,W6 c5— CERS ID: �(]� <br /> I certify under penalty of law that: <br /> 1. 1 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 belleve the information to be true,accurate,and complete: <br /> ->—C——Photos Paperwork �� - -Statement <br /> 3. 1 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 /> imprisonm nt for known violations. (HSC 25191) <br /> Nam �J�, �° ��•^ Ti#le: /�,� f.�I� � 2_ <br /> Signatur Date:, <br />