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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stock(on , California 95205.6232 <br /> Telephone , (209) 468-3420 Fax: (209) 468-3433 Web: wv,P,v. sjrcv . oro;ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be Corrected within 30 dans of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department ( EHD) address <br /> at the top 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 /> For this certification to be complete , the ooerator 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 records/other appropriate paperwork , and/or photos verifying <br /> corrections <br /> Inspection Date : October 10 , 2018 Inspected By : ELIANNA FLORIDO <br /> Facility Address : 520 W LODI AVE , LODI CERS ID : 10180583 <br /> I certify under penalty of law that : <br /> 1 , t 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 _ X 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 : 1 t (� (� <br /> Signal Date: ' t 3 ` f' y <br /> * <br />