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10/10/2016 13:03 209367 424 BAGLEY ENTERPR PAGE 02/02 <br /> "ED <br /> San Joaquin County RECEN <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 0 C T 10 2016 <br /> Telephone:(209)468-3420 Fax:(209)4683433 Web:www. iaov.org/-ehd <br /> RETURN TO COMPLIANCE CERTIFICATION ENVIRON <br /> ENTAL HEALTH <br /> Any MIN0 violations noted in the"Notice to Comply"in the attached Inspection Report must be co ed within 30 daY&of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1,2(c)(1) <br /> All correctlo,ns to other iolations 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 recordslother appropriate paperwork,andlor photos verifying corrections <br /> Inspection Date: September 16 2016 Inspected By: FATINAH ZAREEF <br /> Facility Address: 1331 S HAM LN LODI EFA ID: <br /> I certify under penalty of law that; <br /> 1. 1 have cornacted 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 comp te: <br /> Photos 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 <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name_ Title? o -{ <br /> r <br /> Signature: �' Date: !o r o /G <br />