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Fag undes ' 10th Street 209 -8354567 p . 6 .A f fi' 4 �� , 2 E Tar iiri f ' 1 � rv1 ental Y_.r -, '°` � � '''� �". , !' � ;iB _ Silk .t�� - a :.,<T E a h-. . e �i� a h G � l•,vf s we i ' FgPar 81 10 RErU T %C) COMPLIANCE CERTIFICAT ION 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 the Environmental Health Department ( EHD ) address at the top of this form within 30 days of receipt of the Inspection Report, HSC 25404 . 1 . 2 (c) ( 1 ) 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 in the Inspection Report . HSC 25185 (c) (3) € ote : All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate . For this certification to be complete , the operator of the site must include : A statement documenting what corrective actions were taken or will be taken for each violation Copies of sample results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections Operator' s certification Inspection Date : " - Inspected By : = _I^v = .Facility Address : : k" t , � 1 lf� : =s c<.' `"+, i :; I certify under penalty of law that: 1 . 1 have corrected the violations specified in the Inspection Report from the above- mentioned inspection date . 2 . 1 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 Statement 3 . 1 am authorized to submit this certification on behalf of the Respondent . 4 . 1 am aware that there are significant penalties for submitting false information , including the possibility of a fine and/or imprisonment for known violations . ( NSC 25191 ) F .-) r- Narne : f: �. 0 ) 1 " � �,) i ,K l � �' 1 Title : �- _ �.. Signature : 7o i Date : Ad 7 20115 ENVIRONMENTAL HEALTH PERMIT/SERVICES �I 185(1; E - 1. faze 15cn Avenue Staciaon , California 95205 ! 209 45Y - 347_0 t= 209 464- 0138 ;`/vV�w , stcehd . Cc) m Received Time Apr . 17 , 2019 3117PM No . 4941 _- _ -- -. ___ _ ------- - ----_ - _.