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SAN JOAQUIN Environmental Health Department <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 violatons 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 olhenvise specified in the <br /> Inspection Report HSC 25185(ex3) <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 indude- <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/mardestsrtraining records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: May 15, 2019 Inspected By: CLAUDIA h1URO <br /> Facility Address: 11793 N MICKE GROVE RD, LODI CERS ID: 10180563 <br /> I 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 personalty examined the fol owing 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 cerbfication 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 im risonment for known n tions. (HSC 25191 ) <br /> Name-, /PS ! Title; r��K �Qt� y ( t? l;Jbo/ <br /> Signatu Date: , lig <br /> 0 / 9 <br /> 1868 E. Hazefton Avenue I Stockton, Califomia 952051 T 209 468-34201 F 209 464-0138 1 ww,vw. sjcehd.com <br /> FjEcEN ED <br /> 3ug 19 Z 19 <br /> *JIRONMENTAL HEM" <br /> DEPARTMENT <br />