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II <br /> t t j <br /> lid. rInv 182021 <br /> Envircanmental Health DeRar{ ment <br /> SAN JOA01UIN <br /> ENVIRONMENTAL HEALTH <br /> DFPART (� <br /> RETURN TO COMPLIANCE CERTIFICkCT1 ; N <br /> 1/ cladis If <br /> Any h11NOR violations noted In Iho 'Notice to Comply' in the attached Inspection Report must be corrected, —vrtlhn 3 address al <br /> receipt of this Inspection. This certification form must be submitted to the Environmental Health Department (EHD) <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 certificallon and returned to EHD within 30 days unless otherwise specified In the <br /> Inspection Report. HSC 25195(c)(3) <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be billed <br /> at the currant hourly rate . <br /> r� <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 /> JCopies of sample results/manifests/lratning records/other appropriate paperwork, and/or photos verifying corrections <br /> Operators certification <br /> Inspection Date: October 06, 2021 Inspected By: VICKY YANG- LEE <br /> Facility Address: 200 COMMERCE ST I/ 101 , LODI CERS ID : 104184575 <br /> IFW <br /> I certify under penally of law that: <br /> 1 . <br /> [ have corrected the violations specified in the Inspection Report from the above-mentioned inspection dale. <br /> i <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> a and I believe the information to be true, accurate, and complete: <br /> a - / <br /> Photos Paperwork V Statement <br /> qr��J1 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4 . I am aware that there are significant penalties for submitting false information , including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191 ) �I <br /> f - _ <br /> Name: p <br /> Title :. Q,o�' <br /> Signature: <br /> - Date: <br /> i <br /> t <br /> a <br />