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SEP 0 3 2021 <br />3 A N' O A Q U f N Environmental Health Department <br />C o W r41 T `( ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any M►NOR 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 (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 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/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />Inspection Date: <br />August 10, 2021 <br />Facility Address: 213 S KELLY ST, LODI <br />I certify under penalty of law that: <br />Inspected By: <br />VICKY VANG-LEE <br />CERS ID: 10180645 <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 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 />Photos � Paperwork _Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significarit penalties for submitt <br />ing false information, including the possibility of a fine and/or <br />imprisonment for known violations. (HSC 25191) <br />Name: <br />Signatu <br />Title: <br />Cnvirctrrle�-� ��sulh�f <br />9/3 /Lc)zl <br />