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Environmental Health Department <br /> SHAD Ultl <br /> t;a f '"� C©U N Y--- <br /> Greatness 9(c s here. <br /> R TURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the" otice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certi cation 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 no ed 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 ass ciated with failing to comply by the above noted dates will be <br /> billed at the current h urly rate. <br /> For this certification toe <br /> complete, the operator of the site must include: <br /> A statement documenting hat corrective actions were taken or will be taken for each violation <br /> Copies of sample results/m nifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: Decem er 03, 2018 Inspected By: CESAR RUVALCABA <br /> Facility Address: 18133 DE VRIES RD, LODI CERS ID: 10186015 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violatio s 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 Paperwork Statement <br /> 3. 1 am authorized to submit t is certification on behalf of the Respondent. <br /> 4. 1 am aware that there are si nificant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for kno n violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> 1868 E. Hazelton Avenu I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />