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AN , JOAQUIN Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIP IJ NOR violations Luted in the"Notice to Comply"In the attached Inspection Report must be corrected vi50�da of <br /> receipt of this inspection. This certification form must be Submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 30 days or receipt of the Inspection Report. HSC 25404.'1 2(c)(1) <br /> All coinections to other via at an, noted in the Slashed Inspection Report(I R)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otheRVISe specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All END 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 doeumeming what corrective actions were taken or will be taken for each violation <br /> Copies of sample msults/manifestsdraining recordsiother appropriate paperwork, and/or photos verifying corrections <br /> Operator s certification <br /> Inspection Date: April 23, 2019 Inspected By: CESAR RUVALC.ABA <br /> Facility Address: 24717 E BRAI4DT RD. LODI CERS ID: 10183309 <br /> I certify under penalty of lava that. <br /> 1. I have contacted the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the'mfermetlen to be true,accurate,and complete' <br /> Photos, �tl"_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 are fine anti/or <br /> imprisonment for known violations_ (HSC25191) <br /> Name: �r-JgH 1 Fct rJ 2.k`,) Ti C �uJ1ic ;a9�n�nrl�'1Nrt�!1vf�' <br /> Signature: `°y J - Date: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 46T.3420 1 F 200 464-0138 1 www.sjcehd.com <br />