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SAN W O } I I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Arty MLNjQ.R violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> reaetgt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD ) address at <br /> toe Doti urn of this form within 30 days of receipt of the Inspection Report . HSC 25404 . 1 . 2(c) ( 1 ) <br /> Ali cLrregtions to other violations noted in the attached Inspection Report ( IR ) or Continuation Form , or disputes to any <br /> viAol,rajhons , are to be submitted using this certification and returned to EHD within 30 days 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 <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 Hate : December 02 , 2019 Inspected By : SHEWIT WOLDEARECAY <br /> I <br /> Facility Address : 1097 YOSEMITE AVE , ESCALON CERS ID : 10180561 <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 date . <br /> 2 . 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 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 and/or <br /> imprisonment for known violations . ( HSC 25191 ) <br /> Name : 1l� Title : `1,117er <br /> Signature : Date : <br /> � icra <br /> .�.� <br /> i <br />