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"'A"�- Environmental Health Department <br />SAN��JOAHIN <br />a r. <br />'�t�s+,n�t,:p:" Greusrau glows hire. <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 Envirdnmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1'.Z(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 uplass o(herwise 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 operatorofthe 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 recordslother appropriate paperwork, end/or photos verifying <br />corrections <br />Operators certification <br />Inspection Date: March 09, 2018 Inspected By: AARON HANG <br />Facility Address: 14900 W HWY 12, LODI CERS ID: 10180619 <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 We, 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 violabons. (HSC 25191) <br />Name:_-S)C'K Title: d�/ <br />Signature: I/ e. tw a Date: iI 3 a01 K <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwws)cehd.com <br />