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SAN_10ANIN <br /> Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected_1Nithin30days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of <br /> 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, <br /> or disputes to any violations, are to be submitted using this certification and returned to EHDiw thin <br /> 30 days unless otherwise specified in the Inspection Report. HSC 25185(cx3) <br /> Note: All EHD staff time associated with falling to comply by the above noted <br /> dates will be 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, <br /> and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: temberll 2 8 Inspected By: Cesar Ruvalcaba <br /> Facility Address: 500 N. Cluff Avenue, Lodi, CA CERS ID: 10182979 <br /> 1 certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Reportfrom the above-mentioned inspection date, <br /> 2. 1 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 X Paperwork X 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 <br /> and/or imprisonment for known violations_ (HSC 25191) <br /> Name:Nick Anes Title: President <br /> Signature: *S' Date: 115-76,11b <br />