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i <br /> x Environmental Health DepartmentSAN ; <br /> ff COUNTY, <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations poked in the"hltkice to Comply" in the attached Inspection Report must be corrected within 30 May of <br /> receipt of this inspection. This certification form must be submitted to the Errvironmontal Health Department (EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspectlon Report, HSC 25404.1,2(rz)(1) <br /> All cormAjOns to other VJolations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any <br /> violations, ire to be submitted using this cert`rfication and returned to EH 1)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 /> Coples of sample resultslmanifeaWraining recordslother appropriate paperwork, findlar photos verifying corrections <br /> Operator's certification <br /> Inspection Date: September 17, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 10979 N MI KE GROVE RD, LODI GERS ID: 10663819 <br /> certlly udder penalty of law that: <br /> 1. l have corrected the violations specified in the Inspection Report from the above-menfioned inspection date. <br /> 2. 1 have personally examined the following dacurrrantallon submitted as proof of complianca FOR EACH VIOLAT 10N <br /> aiid I believe the information to be true, accurate, and complete: <br /> -Photos-Paperwork�Statement <br /> 1 1 am authorized to submit this certificat.ion on behalf of the Respondent. <br /> 4_ 1 am aware that there are sign IFicant penalties for subMitting false infonnatlon, including the possibllfty of a fine andl( <br /> imprisonment for known violations. (1-115 25191) <br /> Iu�nrrd Cis <br /> Name: Title: <br /> 1r�stcre; <br /> Date: � <br />