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SAN JOAQUIN Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any Mw violations noted in the 'Notice to Comply" in the attached Inapechon Report must be 30 30 of <br />mApt of this inspection. Thii certification form mubt be submitted to the Environmental Health Department (EHD) address at <br />the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(~)(1) <br />Ail . . noted in the attached lnepedion Report (IR) or Continuation Form, or disputes to any <br />viohths, are to be submitted using this certification and returned to EHD unless otherwise specilSed in the <br />lnbpection Report. HSC 251 85(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dabs will be billed <br />at the current hourly rate. <br />For this certification to be complete, the operator ofthe site must indude: <br />A dstement documenting what corredive actions were taken or will be taken for each vidation <br />Copies of sample resulWmanMs/training morddother appropriate paperwork, andlor photos verifying corrections <br />Operatdscertitication <br />April 26, 2021 Inspected By: JOHN ALANIZ <br />Facility Add-: 6421 CAPITOL AVE, LODl CERS ID: 101 80605 <br />I certify under penalty of law that: <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the infomKltion to be true, accwate, and complete: <br />I X Photos Pap- Statement <br />1 3. 1 am authorized to submi this catlfica6a, on behalf ofthe Reapondent. <br />I 4. 1 am aware that there am significant penatties for sukning false information, including the possibility of a fine <br />andlor knprisonment for known violations. (HSC 25191) <br />I Name: . Haleh Amiri Tile: Envirmental Coordinator <br />Signature: 5/27/2021