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z�Ca 6( 4 ► r � ►31 �3 <br /> SAN , a A N 1 N Environmental Health Depai• :' ment <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 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 Date : November 15 , 2023 Inspected By : PAUL NSO <br /> Facility Address : 620 W DR MARTIN LUTHER KING JR BLVD , S CERS ID : 10181363 <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 I believe the information to be true , accurate , and complete : <br /> Photos Paperwork Statement <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 and /or <br /> imprisonmeent for known violations . ( HSC 25191 ) <br /> Name : J l/ �. I Title : oci <br /> Signature : Date : r c� � C <br />