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SO JOAOUIN <br /> Enviro mental ealth Department <br /> p <br /> f w.1 lei .. <br /> I• � i I <br /> RETURN O COMPLIANCE CERTIFICATION <br /> Any MINOR viplations noted in the"Notice to Com ply"in the attached Inspection Report must be correctedwithin 30 days of <br /> receipt of this inspection. This certification form ust be submitted to the Environmental Health Departme t(EHD)address at <br /> the bottom of this form w thin 30 days of receipt Of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other vi lations noted in the atta hed 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 /> lnspection Reprt. HSC 5185(c)(3) <br /> Note: �at <br /> ' EHD fF time associate; with failing to comply by the abolve noted d tes will be <br /> bi11e the urrent hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A sta4ment documenting what correctWe actions were taken or will be taken for each violation <br /> Copied of sample results/manifests/tradii ig recordslother appropriate paperwork, and/or photos y rifying corrections <br /> Opera or's certiftation <br /> i <br /> Inspection ate: October 21, 2020 Inspected By: CAROL PRESTO <br /> Facility Ad ress: 20 W TURNER RI #A, LODI CERS ID: 1 D 180633 <br /> f <br /> I certify under penalty of aw that: <br /> 1. 1 haye corrected the violations specified i the Inspection Report from the above-mentioned inspe tion date. <br /> 2. I have personal y examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe th information to be true,: ccurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am outhorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am ware that there are significant penalties for submitting false information, including the possi ility of a fine <br /> and/or imprisonr tent for known violation$ (HSC 25191) <br /> Name: > N.2Title: - <br /> Signature: Date: <br /> I <br />