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i <br /> I+ I+ Environmental Health Department <br /> n S A F f`�+4�J � 1 1 1 <br /> O <br /> I�}�+ , <br /> COUNTY <br /> .et <br /> RETURN N T OMPLIAN E CERTIFICATION <br /> Any NOR violations noted in the"Notice to Comply' in the attached Inspection Report must be corrected within 30 da"of <br /> receipt of this inspection. This certificafion form must be submitted t6the Environmental Health Department(EHD) address ad <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 2-3404.1_ (c)(1) <br /> All IPrections to other vtolatlons noted in the attached Inspection Report (IR) or Contirfuation Form, or disputes to any <br /> violations. are to be submitted using this certificatlon and returned to EH within 30 days uniess otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be <br /> Filled at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A stalsmer,!docurneMag what corntdre aatkm were taken or wW be taken far`eac4 tr stiarr <br /> Copies of sample resuILsimanifestsfkraining recordslother appropriate paperwork, andfor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: a tp ember 16, 2020 Inspected By: ROBERT LOPEZ <br /> Facility Address: 9025 West Ln, StocMon CERS ID: 10144367 <br /> ce0ify under penalty of law that: <br /> 1. t have =Trcfed tile WOWWS speCded iff the trrsp6ctfOrt depart from the atso+re-txterltrsr rrrspB(ftn 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(rue, accurate, and complete; <br /> !Photos _ PaperworkStatement <br /> a_ I am authorized to submit(his certification on behalf of the Respondent_ <br /> 4_ lam aware that there are signifioan( penalties for submitting false information, including the possihility of a fine andA <br /> imprisonmentfor known violations. (HSC 25191} <br /> r�d D�N�rdWpwkaxnel+r�l� <br /> Name: �mTitle; <br /> Signature: Date: 1111AQ <br />