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SANJOAQUIN <br />Environmental Health Department <br />—C 0U N T Y. ---- <br />,: <br />r {.*'i CISP, nbt .t „rl"iS iSt"Y('. <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 da vs of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHO) 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: September 21, 2023 Inspected By: MICHAEL SUSZYCKI <br />Facility Address: 26 N CHEROKEE LN #A, LODI <br />I certify under penalty of law that: <br />CERS ID: 10184133 <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and 1 believe the information to be true, accurate, and complete: <br />Photos X 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 and/or <br />imprisonment for known violations. (HSC 25191) <br />Name: ©/7 Title: �iGe9n�— <br />Signat Date: �L/ <br />