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SQN,_)OAQUIN <br />_ C:C>1.3i�ITY <br />Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION fn <br />Z <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of 57 <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHO) addree 0 <br />at the lop of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) 'm0 Z <br />D � <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any M z <br />violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified In the' Z <br />Inspection Report. HSC 25185(c)(3)ffl D <br />: <br />Z E <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be I <br />billed at the current hourly rate. D <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 reoordstother appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: December 26, 201' Inspected By: CESAR RUVALCA3A <br />Facility Address: '1400 E VICTOR RD, LODI CERS ID: 10181325 <br />1 certify under penalty of law that: <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 I believe the information to be true, accurate, and complete: <br />Photos 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 />andlor imprisonment for known violations. (HSC 25191) <br />M <br />M <br />o <br />m 0T <br />C-> 1 1 a <br />t -Z <br />N_ <br />ti <br />Itl <br />iDl ; vsi r�n`i n S�teVbm was up6t -W ovrd sL(Oftited fb CM5 oh 12Ja&,117 <br />2oet.�nfo+rrect one�te fec�lr'ctah OF date Giiscreptep4to em>tere. accwury wl�ch <br />p,y y.�YrALh tj V- wO VX Mj ins re dw t*IS at -ttu -AaC.i (i �y <br />1868 E. Hazelton Avenue I Stockton, California 96205 1 T 209 468-34201 F 209 464-0138 1 www.sicehd.coni <br />