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SAN MOM 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 corrected within 30days 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 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 /> l <br /> ort is certification to be complete, [he operator othe 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,andlor photos verifying comections <br /> Operator's certification <br /> Inspection Date: May 09 2019 Inspected By; CESAR RUVALCABA <br /> Facility Address; 1126 E PINE ST, LODI CERS ID: 10181397 <br /> 1 certify underpenally of law that: <br /> 1. 1 have connected 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 and <br /> I believe the Information to be true,accurate, and complete. <br /> ✓photos Paperwork t/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 end/or <br /> imprison enl for known violations. (HSC 25191) <br /> Name: „ K� Title: <br /> 1868 E. Hazellon Avenue I Stockton, California 952051 T 209468-3420 1 F 209 464-0138 1 www.sjcehd.wm <br />