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131 <br />1 <br />• SAN JOAQUIN COUNTY a uI ECE " E D <br />ENVIRONMENTAL HEALTH DEPARTMENT ��C Z 1 200d <br />304 East Weber Avenue, 3d Floor, Stockton, CA 95202-2708 <br />209 468 3420 F • 209 468 3433 Weh• <br />T hd <br />eleph <br />one. ( ) az ( ) www.sieov.or <br />EN11!Q;')��r•:^Cry? s1EaLTH <br />Gr;a: nl rIsm, ICES <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 35 days of receipt of the <br />inspection report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br />unless otherwise specified in the IR. <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 <br />verifying corrections <br />• Operatot's certification <br />Inspection Date: 11-13-300'6 Inspected By: f\Y I S COCU p M <br />Facility Address: 1333 E TUMF,?, Rd i LODI EPA ID4:CK DOOlC14411 <br />:I certify under penalty of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos i< Paperwork X Statement <br />3. I 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 <br />npossibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />M � <br />EHD 22-02-005 Rev 12-04 <br />Date: R -b -?00b <br />