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� A � Environmental Health Department <br /> { tare SAN . <br /> `' "✓ kiY.:-i ....�.. C 0 LJ i l elm Y .0 <br /> t ( p (/ t110E5 9110111S' hp, re , <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyiNm cit 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 bottom 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 EMR 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 corrections <br /> Operator's certification <br /> Inspection Date: June 12 , 2019 Woomp Inspected By : ZUNA BARKER <br /> Facility Address : 205 W LOCKEFORD ST , LODI CERS ID : 10180641 <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 /> Photos X Paperwork X Statement <br /> i <br /> 3 . 1 am authorized to submit this certification on behalf of the Respondent. <br /> r <br />� 4. I am aware that there are significant penalties for submitting false information, Including the possibility of a fine and/or <br /> Imprisonment for known violations. ( NSG 25191 ) ` f t1� <br /> I <br /> Name : P Title : V U( (C F� /�'t Qik- <br /> Sign ure : Date : Ilk I L <br /> 1869 E. Hazelton Avenue Stockton , California 95205 T 209 46B-34201 F 209 464-0136 I www.sjcehd. com <br /> i <br /> i <br /> F <br />, <br />