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RECEIVED ON 11/30/2021 VIA EMAIL <br /> SAN J O Q U I Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIN92 vlolatons noted in the'Notice taComply'in the attached Inspemn Report must be corrected within 30 days of <br /> receipt of this inspection. This certirica�on form must be submitted to the Environmental Health Department(EHO) address at <br /> the bottom of this form vrithin 30 days of receipt of the Inspection Report, HSC 25404,12(c)i1) <br /> At corgi,#ions to other viol#ions noted in the attached Inspection Report(A)or Continua#ion Form, or disputes to any <br /> vrola#ions. are to be subrnitt9d using this oertific2itiorl ari0 rete reed to E H D within 30days unIe�.s otherwise spacffi 1�d in the <br /> Inspection Report. HSC 2518 (c)( ) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates wi[I 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 wheat corrective actions were t2 ken or gill be t5kken for each violation <br /> Copies of sample fesultslrnanifestsftraanin9 rcoudslot her appropriate paperwork. anWor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: November 04, '2021 Inspected By. Il~KY VAN -I EF <br /> Facility Address: 610 S CHEROKEE Ln. LODI CERS ll]: 10184805 <br /> I certify under penalty of law that: <br /> 1 k hnva corrected the vinlations specified in the Inspectinri Repnrt from the ahave.mFntinnad inspection data <br /> 2, 1 have personally examined the€oltowing documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the infofrnatian to be trua, acQvrate, and oornplete. <br /> x photos?Paperwork x statement <br /> 3. 1 Pm aulhoiized to 6ubmit#tris carl:McAon on behWi of the Respondent, <br /> 4. I am aware that there are significant penalties far submitting false information, including the posaftlity of a fine andfor <br /> irnprisonmant far known vioiat!ons ( 251 1) <br /> Name: JU1-iQROSE Title: MANAi3ER <br /> Signature: Date. �1l3ori} t <br />