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H I �DK'Jt11 QI1 � Environmental Health De �o �yv-nnen <br /> - (a r ;' r Cr, i: � i ,� ra� s•, c r`t r' r {•. <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 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 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 /> Inspection Date : February 05 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address : 1126 E PINE ST , LODI CERS ID : 10181397 <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 complete : <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 /> Names y Title : �J � <br /> Signature : Date : dZ-\ O ` � C <br /> •1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 I F 209 464-0138 1 www. sjcehd . com <br />