Laserfiche WebLink
FIRM <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stockton , California 95205-6232 <br /> Telephone , ( 209 ) 468-3420 Fax: (209 ) 468-3433 Web : www.sipov.gW/ehd <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 (EMD) 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. MSC 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/manifestsltraining records/other appropriate paperwork, and/or photos verifying <br /> corrections IF NO IF <br /> Inspection Date : July 30 , 2018 1 Inspected By : ELIANNA FLORIDO <br /> i <br /> Facility Address : 330 E KETTLEMAN LN , LODI CERS ID : 0 <br /> I certify Under penalty of law •that: <br /> 1 . I have corrected the violations specified in the Inspection Report from the abbve- enti <br /> moried inspection date. <br /> 2v i 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 /> I OFt <br /> Photos OF Paperwork, Or ZStatement . <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent . <br /> IF F <br /> 4. F. I am aware that there are significant penaltiesfor submitting false information , inpluding the possibility of a fine <br /> OF <br /> and/or imprisonment forF mo_ m violations.. (HSC( 25191 ) Or <br /> Name: 0 , F aha 'M12?�� � t �° IM Title : � <br /> Signature: ate : �- <br /> — -�r . <br /> -� <br /> t, ' d LO£L69 £ e.n} }unoosip }ue10 eL £ : 60 ' 81, 4 £ 100 <br />