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05 / 04 / 2022 16 : 08 FAX 2094732214 DAVITA Z0002 / 0010 <br /> . N « Environmental Health Department <br /> cc P <br /> RETURN TO COMPLIANCE CERTIFICATION <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 at <br /> the bottom of this form within 30 days of receipt of the Inspection Report , HSC 25404 . 1 . 2 (c) ( 1 ) <br /> All corrections to other violations noted in the attached Inspection Report ( IR) or Continuation Form , or disputes to any <br /> violations , are to be submitted using this certification and returned to EHD within 30 dais 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 billed <br /> 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 Date : April 29 , 2022Inspected By : ROBER � LOPEZ <br /> Facility Address : 7x00 �/l/ 1 I� N , !C7Gl� T' CN CERS ID : 10873174 <br /> I certify under penalty of law that : <br /> 1 . 1 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 I believe the information to be true , accurate , and complete : <br /> . Photos PaperworkStatement <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 violation ( HSC 25191 ) <br /> Name-- �Cii/1l � �'i'�ailC• 5�,�7 Title : 9i <br /> Signature : Date : <br /> — 02 <br /> Rece1ved _Time May 4 . _ . 2022 , 3 : 56PM .. . No , 7188 : : . , _. <br />