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Environmental Health Department <br /> SAN 10A Q U I N <br /> COUNTY - <br /> _ i � r • . I i7r . , . 1i , <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 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 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 corrections <br /> Operator's certification <br /> Inspection Date : June 19 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address : 255 E Harney Ln , Lodi CERS ID : 10484500 <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 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 and/or <br /> imprisonment for known violations . (HSC 25191 ) <br /> Name :. )7;q e La C) a Title : ' "� a�cr <br /> Signature : / n ✓If Date : l "L <br /> RECEIVED <br /> JUL 1 :`l 2019 <br /> ENVIRONMENTAL ISE/ LTH <br /> DEPARTMENT <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-3420 1 F 209 464-0138 I www. sjcehd . com <br />