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SAN JOAQUIN Environmental Health Department <br /> - CUNT " Y - - <br /> v .' P ^ ; n. t55 rKr' O �: S ftFrB . <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 : May 21 , 2020 Inspected By : ELIANNA FLORIDO <br /> Facility Address : 2415 W Kettleman Ln , Lodi CERS ID : 10636075 <br /> I certify under penalty of law that : <br /> 1 . I have corrected the violations specified in the Inspection Report from the above - mentioned inspection date . <br /> 2 . I 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 and / or <br /> imprisonment for known violations . ( HSC 25191 ) <br /> Title : <br /> Signature : Date : to <br /> ( Rei o�+ arvr< etic� � 5I aq J � a <br />