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r <br /> San Joaquin County RECEIVED EIVED <br /> Environmental Health Department NOV Z 2 206 <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicov.oro/ehd EWIRRNIMENTAL HEALTH <br /> r <br /> RETURN TO COMPLIANCE CERTIFICATION PERMiLCERVICES <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 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 mustinclude: <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: November 02, 2016 Inspected By: FATINAH ZAREEF <br /> Facility Address: 308 N CHEROKEE LN, LODI CERS ID: 10186855 <br /> 1 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 1r 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: 7-4-400 r2A Title: "4V,4 C*[rr' <br /> Signature: — - Date: <br /> /I Af" /+A ZA g 4)00 S WASTE G OA)I- r}/,t/o-jq <br /> TACj, 1,-02 14AzAAvocrs W457b. co,,u7 <br /> ,4 1,,j <br /> �) /E&G M A 1zA4 OD vs /,tf.4s rr Ajo&-J ry Bvr �i�sioFr <br /> / <br /> 3) ALI?C l7Y App" Y of si��/ Ttft�— oi9�'b�z 7=0 q Nc_w V4LJO <br /> � D NUMgtjn �� 77fE,r CvalC1 T 0L)SXV6F55 Ao,404Cr- <br />