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4T7 -r1 1� -r ,' // <br /> San Joaquin County <br /> Environmental Health Department RECEIVE® <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sioov.ora/ehd NOV Z 3 2016 <br /> RETURN TO COMPLIANCE CERTIFICATION ENVIRO '' EN,4LH 7N <br /> O <br /> PERMIT/SERVICES <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 <br /> at the top 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 te-comply-by-t!M.eabove+leted elates WU-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 <br /> corrections <br /> Inspection Date: October 14, 2016 Inspected By: FATINAH ZAREEF <br /> Facility Address: 26 N CHEROKEE LN, LODI CERS ID: 10184133 <br /> 1 certify under penally 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 <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: j���T/�L ✓r Title: �UsyL� lam' <br /> Signature y Date: <br /> 7—All ST 01T 6-- <br /> &�,IV s T-��Trr�� i,7- � +z <br />