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.# <br /> AV <br /> w�► yi Jf <br /> 0 1 <br /> - <br /> : , , ; . i 7 <br /> tom • ' <br /> : : . D <br /> �lov 1 . 8 u7i1 , r ; srtment <br /> SAN JOAQUIN <br /> ENVIRONMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERT$D;qR1MENT <br /> Any M111NOR 001alions noted in the 'Nollco to Comps In (ho attached Inspection Report must be co actod within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Hoal(h Department (EHD ) address at <br /> the bottom of lhfs form ivilhfn 30 days of receipt of the Inspection Report. HSC 25404 . 1 2(c)( 1 ) <br /> r <br /> All corrections to other violations noted In the attached inspection Report (IR) or Continuation Fofm, or disputes to any <br /> rf vfofallons, are to be submllled using this certification and resumed to EHD wllhln 30 days unless otherwise specified In the <br /> Inspection Repor. HSC25185(c)(3) <br /> t <br /> Note: All EHD staff time associated wilt falling to comply by the above noted dates will be billed <br /> f� at the current hourly rate. <br /> , <br /> —�—� For this certification to be complete , the operator of the site must include: t <br /> - A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample resuifs/manifestsliralnin records/other appropriate paperwork, and/or photos verifying corrections <br /> r. Operator's certification <br /> r <br /> Inspection Date: October 06, 2021 (SKY VANG - LEE <br /> Inspected By: 11 <br /> Facility Address: 200 COMMERCE ST # 101 , LODI CERS ID : 10184575 <br /> I certify under penalty of law that: <br /> 1 . I have corrected the violations specified in the Inspection Report from theabove-mentionedinspection date . <br /> - t 2_ 1 have personally examined the following documentation submitted as proof of Compliance FOR EACH VIOLATION <br /> _ and I believe the information to be We, accurate, and complete : <br /> r Photos Paperworky.Slatement <br /> 3. 1 am authorized to submit this certificat on on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penallies for submitting false information , including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191 ) <br /> Name: � 0 �_i. <br /> r <br /> Title :_[ <br /> Signature: <br /> Date : . <br /> i , <br /> 1 <br /> i <br /> i <br /> i � 1 <br /> r <br />