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San Joaquin County R, ECENED <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web:wwwsi ov.oralehd SIP 10 (5 2 01 7 <br /> RETURN TO COMPLIANCE CERTIFICAT10WONMENTAL HEALTH <br /> DEPARTMENT <br /> Any NINQR 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 /> Ali 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 jQdays 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 /> Inspection Date: August 30, 2017 Inspected By: ELENA MANZO <br /> Facility Address: 13850 N DE VRIES RD, LODI CERS ID: 10181479 <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 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 /> PhotosP <br /> %, le aperwork izKStatement <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 viol ons. (HSC 25 1) <br /> r f—." <br /> Name: ,A Title. -iodd <br /> Signature: Date. <br />