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Environmental Health Department <br /> SW- j0A 0 U I <br /> C n. UN71' Y <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 days 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 /> For this certification to be complete , the operator 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 corrections <br /> • Operator's certification <br /> Inspection Date : January 14 , 2020 Inspected By : CLAUDIA MURO <br /> Facility Address : 111 S GUILD AVE , LODI CERS ID : 10184473 <br /> 1 certify under penalty of law that: <br /> 1 . 1 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 _Paperwork Statement <br /> 3 . I am authorized to submit this certification on behalf of the Respondent . <br /> 4 . I 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 2519- 1 )/ <br /> /V <br /> Name : j, ) 1 , N i�-- �-c G , t (/ a Title : <br /> r <br /> Date : - � r <br /> Signature : <br /> ' ! t <br /> ` _ J,; <br /> F� P I F) 202 <br /> ENVIRONMENTAL I-IEA [, TILI <br /> F? ERMIT/ SERVICES <br />