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i <br /> RECEIVeD BY SJC EHD (EF) on 7/3012020 <br /> 1 <br /> E <br /> EnviroImental Health Department <br /> u C;0 U N T Y <br /> t <br /> RETURN TO COMPLIANCE CERTI . ICATION <br /> Any MINA violations.noted in the"Notice to.Gomply in the,attached Inspection Report mu E t be corrected within 30 da of <br /> receipt of this inspection. This certification.form must be submitted to-the Environmental He Ith Cepartinent(EHI])address of <br /> the bottom of this form within 30`days of.receipt of the Inspection Report. HSC 25404:1,2.M 1) <br /> All corrections to other vialations noted in the atta* Inspection Report(1 R)or Gontinuatio i i Form,or disputes to any <br /> vial atians,:are to.be submitted using this certificate On and.returned to EHD within 30.days un ass otherwise specified.in the <br /> Inspection Report: HSC 25.185(c)(3) . <br /> i <br /> Note: All EHD staff time associated with failing to corinply by the above oted dates will be billed <br /> at the current hourly rate. <br /> 3 <br /> For this certification to be complete, the operator of the site must incl u(e: <br /> A statement documenting what corrective actions were taken or will be taken for ea 4 violation. <br /> Copies.of sample'results/manife"sts/training fecords/other appropriate paperwork,a i d/or photos verifying corrections <br /> Operator's certification <br /> s <br /> 1 <br /> Inspection Date: July 29, 2020 Inspectei I By.: ELIANNA.FLORID0 <br /> i <br /> Facility Address: 250 E HARNEY LN3 LODI c RS ID: 1:0778590 <br /> 3 <br /> I certify under penalty of law.that:. <br /> i <br /> 1• 1 have corrected the violations specified iii the Inspection Report from the above4 a rationed inspection date.. <br /> 2. I have personally examined the fallowing.documentatign submitted as proof of co pliance FOR EACH VIOLATION <br /> and 1..believe.the.information.to-he true, accurate, and.complete: <br /> 5 -rPhotos._ Zpaperwork VSt itement <br /> 3. 1 am authorized to..submit.this cart 16n on behalf of the Respondent. <br /> 4• 1 am.aware that there are significant penalties for submitting false.information,•inc iding the possibility of a fine <br /> andlor imprisonment for known violations,. (HSC 251.91) <br /> Name: 3 �,�rll��t �LWi � Title: tr <br /> Signature: Date: <br /> E � . <br /> i <br /> S <br /> 1 <br /> E <br /> 3 <br /> 3 <br /> 1 <br /> E <br /> i <br /> i <br />