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SAN'JOAQUIN Environmental Health Departm <br /> COUNTY—— <br /> .f 151SS ijro'vs here, <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MENOR violations noted in the"Notice to Campy'in the attached Inspection Report must be corrected within 30 dam of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this farm 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/manifestsltraining recordslother appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: —May 10, 2019 Inspected 6y: ELIANNA FLORIDO <br /> Facility Address: 125 Lakewood Mail , Lodi CERS ID: 10406365 <br /> 1 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 and <br /> I believe the information to be true,accurate,and complete: r <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 and/or <br /> imprisonment for known violations. (HSG 25191) <br /> Name: bLrSv Title: <br /> Signature, p Date: 2-1 ZS I 10 2�O <br /> 1868 E.Hazelton Avenue I Stockton,California 952051 T 209 466-3420 1 F 209 4640138 1 www.sjcehd.com <br /> Fcb 25,2020 pg. 3 <br />