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SAN JOA Q I N Linvilronmenrai mealtn uePartment <br /> 066 '°N Ad'` l U06 '6 '2nV ;wil pania�a� <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 /> Operator's certification <br /> Inspection Date: June 20, 2016 Inspected By: ARIS VELOSO <br /> Facility Address: 11401 N MICKE GROVE RD, LODI CERS ID: 10183249 <br /> 1 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 documertation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true,accurate, and complete: <br /> Photos Pa perwo rk—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: Title: <br /> Signature: —� Date: <br /> (RECEIVED <br /> AUG 0 9 2018 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERWES <br /> 1868 E. Hazelton Avenue l Stockton, California 95205 I T 209468-34201 F 209464-0138 I www.sicend.com <br /> 6-d SCW69E60Z anoaE)a�oiw e7£:50 b0`; qW <br />