Laserfiche WebLink
RETUR <br /> TO COMPLIANCE Z € FICATI� <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD ) address <br /> at the top of this form within 30 days of receipt of the Inspection Repot t. HSC 25404102 (c) ( 1 ) <br /> All corrections to other violations noted in the attached Inspection Report ( IR ) or Continuation !corm , or disputes to any <br /> violations , are to be submitted using this certitrcetion and returned to ENC) within 30 days unless otherwise specified in the <br /> Inspection Report . FISC 25155 ( c) ( 3 ) <br /> Note : All EHD staff time associated with sailing to comply by the above. nated plates will be <br /> milled at the current hourly rate . <br /> For this certification to be complete , the operatorofthe site rnustinciude <br /> 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 <br /> corrections <br /> Operators certification <br /> A ;rIcn > G9 Inspected B <br /> 1ns ecey . C: � i t � � <br /> Inspection ate : <br /> wv _ _ _ <br /> Facility Address : 22832 N r-liAlY 99 , A (]> AESP ;:) CER ID : 10 "7 8 811 <br /> I certify under penalty of law that: <br /> i I have corrected the violations specified in the Inspection Report from the above -mentioned inspection date <br /> 2 { have personally examined the following documentation submitted as proof of compkance FOR EACH VIOLATION <br /> and I believe the information to be true , accurate , and complete : <br /> Photos ... Paperwork Statement <br /> 3 i 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 fine <br /> and /or imprisonment for knovn violations . ( HSC 25191 ) <br /> Name :. 0 � =71� +mss , Title : <br /> na <br /> � Igttlre : { .Date : <br /> a �r :. <br />