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1 •� <br /> Environmental Health Department <br /> % 171 : <br /> !: i A` . <br /> or <br /> P . <br /> ,. <br /> 1. <br /> y� ',,; � Lr t..�y fx3�'S S . . <br /> b ] , <br /> D _ � 6Fr�' <br /> wr . . . <br /> P 11 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M NO violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 dgy4 of <br /> receipt of this inspection . This certification form must br) 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 corr ois to othtions 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 da res 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 billed <br /> 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 rewsultsh-nanifests/training records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: February 13, 2020 Inspected By : PAUL NSO <br /> Facility Address: 15600 ,5 HARLAN RD , LATHROP CERS ID: 10180541 -- <br /> I certify under penalty of law that: <br /> 1 , I have corrected the violations specified in the Inspection Report from the above-mentioned inspection dato. <br /> 2 . I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true , accurate , and complete : <br /> __,Photos _,.paperworkStatement <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 firie <br /> and/or Imprisonment <br /> tffor , nown violations - ( HSC 25191 ) <br /> Name : a `' go) Titleto `L <br /> „ too- <br /> Signature: Date: <br /> ►LI <br /> lyM,t i 2020 <br /> ENVIRONMENTAL <br /> i� !:: PAR T MENI <br />