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San Joaqui County <br /> Environmental He Ith Department <br /> 1868 East Hazelton Avenue, St n, California 9 520"232 <br /> Telephone:(209)488-3420 Far:(209)488-3433 Web: <br /> RETURN TO COMPLIA CE CERT FICATION <br /> Any MINOR violations noted in the"Notice to Compal In the site had Inspection sport must be <br /> receipt of this inspection. This certification form must be submi to the Environ ental Health Departmen (EHD) d <br /> the top of this form within 30 days of receipt of the Inspection Re . HSC 254 1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR)or ontinuation Form,or dis as to a y <br /> vlolations,are to be submitted using this certification and returns to EHD unless otherwise s ecified the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with falling comply b the above noted da a wi 1 be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the ope for of the site must include: <br /> A statement documenting what corrective actions were n or will be to an for each violation <br /> Copies of sample resuits/manifeststtralning records/other pproprlale pa (work, and/or photos Yen ng co actions <br /> Inspection Date: July 15 2016 Inspec d By: FATINAH ZAR EF <br /> Facility Address: 320 S CHEROKEE LN Lodi PAID: <br /> I certify under penalty of taw that: <br /> t. I have corrected the violations specified in the Inspection R port from th above-mentioned inspection ate. <br /> 2. 1 have personally examined the following documentallon su milted as oof of compliance FOR EAC VI TION <br /> and I believe the Information to be true, accurate, and camp to <br /> Photos Pape tatement <br /> 3. 1 am authorized to submit this certification on behalf of the ondent. <br /> 4. 1 am aware that there are significant penalties for submitting false info abon,including the possibility a ins <br /> and)orn,#hment for known violations. (HSC 25191) <br /> Name: <br /> Signature: <br /> S�1 ate i o 7� <br />