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SAN <br /> U I 1:=nvironrinental IHealffl Department <br /> rr <br /> UN <br /> RETURN TO COMPLIANCE CEI;i;.TIFICATION <br /> Any MINOR violations rioted in the"'Notice to CompVy" in the attached Inspectic:rn Report must be corrected within ;30 days of <br /> receipt of this inspection. This certification form must be submitted to the Enviri:.nrnental 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 rioted in the attached Inspection Report(IR) c,r Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD withiri,30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: A11 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 ti:aken 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: March 09, 2020 Inspected By:�PAUL NSC) <br /> Facility Address: 18662 N HVVY 88, LOCKEFORD C:ERS ID: 10182137 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the viiolations specified in the Inspection Report from the above-mentior ed inspection date. <br /> 2. 1 have personally examined the following documentation submitted as I;uroof of compliance FOR:EACH '✓IOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> ,_Photos Papenrvork tatement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false inf'orrnation, including the possibility of a fine <br /> and/or irr -r onment for known viol ( C 5191) <br /> Name: . I4! �- <br /> �� Title:---, — <br /> Si nature: /y`-�'" � C1 I <br /> 9 ,�. Date: c� <br />