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SAN <br /> J OA Q u IN Environmental Health Department <br /> i - COUN " fY <br /> l.A . <br /> �� t' tt� tx' BjS (� t' ivr3 �lt � f . <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 . H5C 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 /> vio' Aitions , 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/manifests/training records/other appropriate paperwork , and/or photos verifying <br /> corrections <br /> Operator' s certification <br /> Ins ; ) ection Date , April 25 , 2019 Inspected By : CLAUDIA MURO <br /> Facility Address . 39 N CLUFF AVE , LODI CERS ID : 10186845 <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 proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true , accurate , and com tete : <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 <br /> and/or imprisonment for known violations . ( HSC 25191 ) <br /> Name : w c) L e . �D c er , ' Title : O Wal e r <br /> Signature : Date : <br /> RECEIVED <br /> MAY 2 2 2019 <br /> EUVIRQNMENTAL HEALTH <br /> DEPARTMENT <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464 -0138 1 www . sjcehd . com <br />