Laserfiche WebLink
Environmental Health Department <br /> KK�yNJOAQUIN <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corre ted within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Depart. <br /> ent(EHD)address at <br /> 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 dalte$will be billed <br /> 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 phot�as verifying corrections <br /> Operator's certification <br /> Inspection Date: July 27, 2021 Inspected By: VICKY VANG-LEE <br /> Facility Address: 601 E KETTLEMAN LN, LODI CERS ID. 10181435 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the inspection Report from the above-mentionedlnspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance OR 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 <br /> and/or imprison r known violations. (HSC 25191) <br /> Name:�� <br /> Qnl <&X46 Title: "^ <br /> Signature: Date: <br /> i <br />