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�ar�pnons:(cua)voa sazvrar:�caoa-sgoarreo:vvww.s�mvvraany <br /> RETURN TO COMPLI NCE CERTIFICATION <br /> r_ D <br /> AnyIM NOR violations noted in the"Notice to Comp in the attached Inspection Report must be 052011 <br /> corrected within 30 days of receipt of this inspection. This certification form must be sub mitp the <br /> Environmental Health Department(EHD)address at a top of this form within 30 days of rete k"(WiB'„-1� <br /> Irl; rr.:1 HALT <br /> Inspection Report. HSC 25404.1.2(c)(1) 'VICES <br /> H <br /> All corn . ns to ofh vio noted in the attach Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, are o be submitted using is certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. SC 25185(c)(3) <br /> Note: All EHD staff time associated with bill g to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be cotllp�te the operator of the site must include: <br /> • A statement documenting what corrective accftio ware taken or will be taken for each violation <br /> • Copies of sample resufts/manifests/training r s/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> . Operator's certification 1 <br /> inspection Date: November 4, 2011 — Inspected By:Garrett Backus <br /> Facility Address: 1916 E March Lane EPA IDS: <br /> I certify under penalty of law that: � <br /> 1. I +ave corrected the violations specified in tf Inspection Report from the above-mentioned <br /> insriection date. <br /> 2. 1 have oersonaity examined the following do4imentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the info on to be true, accurate, and complete: <br /> a <br /> Photos .��apervrork Statement <br /> 1 <br /> 3 1 am authorized to submit this certification C1 behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalti4 for submitting false information, including the <br /> possibility of a fine and/or imprisonment for" violations. (HSC 25191) <br /> Name: KA_9AW �T �_Tidw M G'I tL <br /> Signa!ure 4r �"f Date_ - 3 V.-f- I - <br /> EHD 22-02-005 Rev 09/17 <br /> 11 <br />