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Environmental Health lie artment <br /> t KJ QUIN <br /> w COUNTY <br /> greet"e-ss grow$ here. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MSR violations noted in the 4NQtiD@ to QPMply'in the sfta;chad Inspection Report iv+u94 b� c,rr eted wRhin of <br /> raoPipt of this insppeotlon. This wtification fwrm rfiust bo submitted to the Health�part+�ar�t(9H,- )a�dre��a# <br /> the bottom of this f(3Fm within,30 Jaya of roosipt of the In§paCtien Report, HSC 25404.1,2(e)(1) <br /> A!1 corrections to other violations noted in t ottaci^@d lr:6pe4 ion Report(IR)or Continuation Foran,or disputoo tit any <br /> violations,are to be submitter,wing this rrlifieation arid r4turnap fo EHO utithin 3Q days unlets QtI►�rwiso spss,l#�W in the <br /> Inspection Report. HSC 2d185(c)(3) <br /> Note: All EHO staff tirvte 3660 4ted With failing tq comply by the Owe noted dates will, bo Milled <br /> at the eurrent hourly rate. <br /> For this certification to be Complete, the operator of the site muat include; <br /> • A statement documenting what cQrrective actions were tak@n or will be taken for each violation <br /> Copies of sample results/manifests!#raining mw. rd§1othcf ippropri4to peporwork,andlor phAtgs verifying 19rre#Qns <br /> Operator's certification <br /> Inspection Gate: April (ja, 2Q21 In-speptod By; NICHOLA LQi�HRER <br /> Facility Address: 0804 S HARLAN RD, FRENCH CAMP CEPS Iii: 10182713 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the abcve=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: I <br /> Photos--��F'aperwork aStatement <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 <br /> and/or imprisonment for known violations. (HSG 25191) <br /> � <br /> Name: W I Title. <br /> Signature: _a. ,m.. Gate: 1 Lz"I <br /> RECEIVE, D <br /> APP 2 3 20'? <br /> E'NVIRONINIl.YJAI. I Il.w.rrl <br /> 1)E,PAWYNI .n'r <br />