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n tronment3t Health DePartMent <br />SNN <br />/1a/31Zo2/ <br />RETURN T4 COMPLIANCE CERTIFICATION <br />Any MItLCR vi.OWions noted in the -Nalmoe to Comply- in the attauWl Inspej:l+on Report must be C.arrectedwffNn 30 Of <br />receipt of this inspection. This certiftcation farm nnust be submitted to the ErLvironmeDftNI Heaith department (EHD) addr4�sS Ell' <br />the bottom of this Farm within 30 days of rowipt of the Inspection Report- HSG 25404-1.2(cXt ) <br />p,11 oorrectinns to other vialaloons notad in the �ttachad Inspection Report (IR) or Continuation Forrn, or disputes to any <br />violations, are to be submitted using this certification and returned to EKE) within 30 4ays unless otharwis6 specifted in the: <br />Inspection Report. HO25185(c)(3) <br />Note: All EH staff time associated with failing to comply by the above noted dates will be <br />Hied at the current Dourly rate. <br />For this certification to be complete, the operator of the site must include: <br />A statement documerlGng w, at oofFigoive actions were taken or will be taken ror each violation <br />Copies of sample msultOrnanifestsitraining record5fother appropriate paperwork, and+or photos verifying correcl ions <br />Operator's certification <br />Inspection Date: <br />Facility Address: <br />December 13, 2021 <br />16470 CANIBRIDGE T, LATHROP <br />I certify under penalty of law that: <br />Inspected By <br />PAUL NBO <br />CERS lD' 10779784 <br />I. I Mve coxWed the violations specified in the inspection Report from Tile above-merntioned inspection date. <br />2. 1 have personally examined the fallowing d4CUmenteti4n submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the informationto betrue, accurate, and complete; <br />Photos paperwork $latemont <br />3- 1 am authorized to submit chis oarrMcation on behalf al the Respondent <br />4- 1 am aware that thare are signiH cant penalties for submilling false information, including The possiNlily of a fine <br />andlor irnprisorkment for known violations- (HSC 25199 ) <br />Name; Ahr'diur 0 Title: Of"i'l <br />Signature: Date: <br />