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SAS 10AMIN Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached <br /> i�o amental Health Departmenteport must be Wrggj�d address at daYa o <br /> receipt of this inspection. This certification form must be submitted to the Env <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All goons,are to other violations noted in the attached <br /> and returned to EHD within 30 days unless otherwise specified in the <br /> violations, are to be submitted using this certification <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 /> 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 /> c <br /> Facility Address: 1\\�? E . 106,c5n►n CERS ID: <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 VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> X Photos Paperwork Statement <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 information, including the possibility of a fine andh <br /> imprisonment for nown violations. (HSC 25191) <br /> Name: Title: Gds <br /> Signature: Date: l <br />