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Environmental Health Qepartmer t IIII <br /> M .:. . SAJOA <br /> RETURN TO COMPLIANCE CERTIFICATION ` <br /> Any MING violations noted in the "Notice to Comply' ih 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 ( EHb) address at I j <br /> the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404. 1 .2(c)( 1 ) <br /> i <br /> All corrections to other violations noted in the attached Inspection Report (IK) or Continuation Form , or disputes to any <br /> violations , are to be submitted using this certification and returned to HHD within 30 days unless otherwise specified in the I <br /> Inspection Report. HSC 25185(c) (3) <br /> Note : All I= HD staff time associated with failing to comply by the above noted dates will be ! i <br /> billed at the current hourly rate , <br /> . . _ . . . . . . - - -- 11 -- - -- ..- I _.11 _ 11 _111 1 . - --- 11 __ 11_ _11 11. _ . •. .- .—.. 1111__ . __ . . . - - - - .,Fn - -• <br /> For this certification to be complete , the operator of the site must include : ! I <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 : September 03 , 2010 Inspected By : SHEWIT WOLDEAREGAYI <br /> Facility Address : 20 W TURNER RD , LODI CERS ID : 10180633 <br /> I <br /> 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. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the information to be true, accurate, and complete: <br /> Photos Paperwork 4 _ Statement <br /> ; <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 and/or <br /> _imprlsonnlpr]t for known violations, (HSC25191 ) <br /> Name: eL Title: <br /> Signature: Date : <br /> . i <br /> i <br /> ; <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205 T 209 468-3420 1 F 209 464-0138 1 www. sjoehd . com <br /> i <br />