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Rf=1`U tW ?EOMRLI'ANC.E CERTIFICATION <br /> &Any M IN R-violations noted calpt 'N tice to comply' ins,he attaohed Inspecllon,,Report«must be <br /> 0 i �MB Q £ <br /> rect®dwithin 30 siaY�of tje of this inepaction ctertifipatlon form nFt� f txg submitted to the <br /> Envir*ftmental Health Department(ENS) adi}rdss at.tl a tiip of_this,farm withix► Q d y8 of,11ecslpt#f tkts <br /> vlo $' Q tIR) or �lo , 1=0[ or <br /> Alt[�'j�'yy ta� yh }rp inn{thevattacchl'�e[d.�.•.IIn.#,p�cGon # j{ a <br /> d u lrjaP Yi_ (' � <br /> a <br /> unle9a of erw a�H ,. <br /> Nota : !i11 EHl�.si�aff tarxwe �1. stdtEh I`a� hta.' a+ tath00,a � tk <br /> Far 0ii certification t0,:be C ITIP11Athe QP.aratoWtha I kemast uncl,ude <br /> • R trtt�twmo dooumanting what Correct;,+ eptl N i <br /> ' bl <br /> i" <br /> "Copka of Sample r9$uk9tti5ilY11feltttlJtf I !i W, <br /> I <br /> ;xltlf ung coRectioris. ... <br /> bi+atoes certification .. <br /> Y � i k'f11EA.iS j,,. 1,tii�,„�t, S !•c t.i.�'C4 i��divl� f1y�43''4. �� ° .#i{,�-{ _: +�! �'yr✓:. <br /> Inape' <br /> ctlen Date: O! O DC7 In�0ee � IftM r �► ° <br /> F4011 hddlrass.;3 o0 1`rla� ll��, �r. EpPa <br /> T- t. <br /> f cenlfy under pcnaltyi;of tgw that:. <br /> , .: I have borrebted the olatiohe specified In the::.It 0gYegiion pgrt fYprp iR a�b9vp m <br /> 1wantioned: <br /> 2: <br /> t`have personally,examined the following.documentatton.kij4a*AN,Wpra�',K: plisAtwO 9ft <br /> WH VIOLATION and I"believe-the lnformatlon tobeft�gt"d t ttdri�l�EN,tt1�1 <br /> „ . <br /> Photos Paperwork,. i.� '..St#tptnerit <br /> 3. I am authorized to submit-this ceyiftetiori vn berlglf of rile Respvftdent. <br /> 4. 1 am aware that there are signifioant penalties for subini.Am'o�fWs iAfdt.hiation, including thik . . . <br /> pcissibllityof's'fineand/or imprisonment for knownvl6WI61gl irr 5 91j`; <br /> Name; n 7itl#: 10 <br /> Signature: Dater C� <br /> z •d XHJ 13rN3Sd-1 dH Wdas :c 6002 EO Jew <br />