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SAN J O QUI Environmental Health Department <br /> COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIM NDR violations noted in the""ice to Comply"in the attached Inspecllon Report must be carrecl&d within 3D Gaya of <br /> ramipt of this inspection, 'funs certification farm must be submitted to the Environmental Health Dapartmeni�EHD)address at <br /> the bnilom of this forma within 30 days of receipt of the Inspactlon Repon. HSC 2.5404-1,2(cx 1) <br /> All to other violations noted In the attached Inspection Report (IR)or Conlinuat[on Farm,or disputes 1a any <br /> violations, we to be subrnitted using INS oertlficallop and retUtned to EH❑ with In 30 days unless otherwise specif led in the <br /> I nspection Report. HSG25185(cX3) <br /> Note: A]I EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For t is certification to be compiete, the operator of the site rnual include: <br /> A slatement documenting what oDn-cd1vQ acttvns were taken or will be taken for each violation <br /> Copies of sample resullsdmanifestsltrainIng racordsfolher approprlete paperwork,and)or photos vardying cairectio ns <br /> Operators certAmlim <br /> Inspection Date: rt.. + 1ns} ecteci By: c.rrc' r � rwCU.rf <br /> Facility Address: ER ID: 1 �0 ` <br /> I cerlify under penally of l +Ihat <br /> 1, 1 have corrected the violations spechled In the Inspeclion Report from the above-mentlonad inspection data, <br /> 2. 1 have personally examined the following documentation arubmltfad as proof of eomptlance FOR EACH VIO ATION <br /> and I heWeve the Information to be true,accurate, and cornplate; <br /> -X—Photos Paperwork Stalemonl <br /> 3. 1 am sulhorized to submit this cortlflcaliva on bahalf of the Respondent_ <br /> 4. 1 am aware that ihero are significant penalties for submitting false information,including the possibility of a the andfor <br /> imprison nifor known viotations_ (HSC 25191) <br /> Nam L } . .J Title: i ' }' <br /> ignatu Date: <br />