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SAN J DANIN Enviro,rarlE:ntal Health Department <br /> 'I Y. ... <br /> RETURN TO CO PLIANCEE CERIFIFICAT'ION <br /> ny MINOR violations noted in the"Notice to Compl ' in the attached Inspection I I'teport must be corrected)within 30 days olf <br /> eceipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD) address at <br /> he bottom of this form within 30 days of receipt of the Inspection Report:. HSC 25404.1.2(c)(1) <br /> II corrections to other violations noted in the attached Inspection Report(IR) or C:,ontinuation Form, or disputes to any <br /> solations, are to be submitted using this certification and returned to EHD N✓ithin_:30 days unless otherwise specified in the <br /> nspection Report. HSC 251 B5(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed <br /> 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 taik:en for each violation <br /> Copies of sample results/manifests/trainingrecords/other appropriate;pal::nerwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: Mauch 16, 2020 _ Inspec::ted By: PAUL NSC) --_ —_ <br /> Facility Address: 1301 W KETTLEMAN LN, LODI —�--_ ,(,E:Ri ID: 10180585 -- —_ <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 1:,roof of compliance FOR EACH'VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> _Photos Paperwoirk__'*" -,'Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am awar at there are significant enal ies for submittinci false information, including the possibility of a fine <br /> and/or imp riso <br /> meat for known violati s. CHIC 25191) <br /> IVame: �� �r :1 itlle:--_...�✓ � -- -- <br /> Signature, Date: <br /> 9 - <br />