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i <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stockton , California 95205-6232 <br /> Telephone : (209) 468-3420 Fax: (209) 468-3433 Web : www.slgoy. oM/ehd <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 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 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 : August 30 , 2018 Inspected By : ELIANNA FLORIDO <br /> I <br /> Facility Address : 100 W Lodi Ave , Lodi CERS ID : 10180535 <br /> I certify under penalty of law that: { <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date , j <br /> i <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 /> X Photos XPaperwork X 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 : Adriana Morales Title : Sr Environmental Specialist <br /> Signature : MMaha Moyate,t Date : 11 /29/2018 <br /> R E G, f F�* <br /> :. <br /> IJEL 0 4 2018 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTWENT <br />