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SAN J 0 Q Q U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply"In the attached Inspection Report must be corrected wlthln 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 corrections to other violations noted in 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 EHD 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 /> r' A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: Inspected By: <br /> CERS ID: <br /> Facility Address: — <br /> F <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. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOtAT1014 <br /> and 1 believe the information to be true,accurate,and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. .d <br /> 4. 1 am aware that there are significant penalties for submitting false information,including the possibility of a fine andlar <br /> imprisonment for known violations. (HSC 25191) <br /> Name: i n 1 T9? I've- <br /> Signature: ' Date: <br /> p��r1�rr� �� a G <br /> •4tvt a'} a s t r t. w"'�4 <br /> 'if� <br /> 0 <br /> w�s yp.. r',.p/ <br /> rr r•/J 1 w!. '/ J1, tppt ''`•I �.4 .:{ ,~ t ':k;�s a�'.', <br /> I�s�t✓lr �tfa9�t�Y rt� t t r� fi <br /> � I pI x <br />