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07/26/2018 15:21 2094683433 SJC EHD UNIT 3 PAGE 01/01 <br /> SAN JOAQUIN Environmental Health Department <br /> 1v Ii <br /> S„ra,„zrse;a �tnrr> her¢, <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQR violations noted in the'Notice to Comply”in the attached Inspection Report must be corrected w1hin 30 da s 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 acfiona were taken or will be taken for each violation <br /> Copies of sample result9/manifests/training recordS/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operators certification <br /> Inspection Date: December 09 2015 Inspected By: ARTS VELOSO <br /> Facility Address: 200 COMMERCE ST, LODI CERS to: 10l W75 <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. <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: Title: k6V\Qty <br /> Signature: Date: L <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 2051464-0138 1 www,sjcehd.com <br />