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RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the "Notice to Comply" in the attached Inspection :Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to file Environmental Health Department (EHD) address at the top of this form within 35 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified it the Inspection Report. Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate ($98). For this certification to be t OMI)ICte the operator of the site must inclade: a A statement documenting what corrective actions were taken or will be taken for each v✓ olation a Copies of sample results/nanifests,Itraining records/other appropriate paperxork, and/or photos verifying corrections a Operator's certification Inspection Date: Inspected By.. a k m, c� Facility Address: q0 t L(1 � �1 inn EPA ID#: C k_ c; i �% 3 I certify under penalty of law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: _Photos _—Paperwork 1,,,�Statement 3. lam authorized to submit this certification on behalf of the Respondent. 4. lam aware that there are si sridca t penalties or submitting false information., Including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: M 1'(1 4 US L -cz Title: 13 nxxr, 9 9_n�_n(15 RPv 1 1/0? Date: