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SAN JOAQ.JN Environmental Health Department <br /> s- - . <br /> RECF�" 1A <br /> A <br /> V D <br /> RETURN TO COMPLIANCE CERTIFICATION 0C� 3 1 2017 <br /> Any MINOR violations noted in the'Notice to Comply"in the attached Inspection Report must be correctad-w'JWQ <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health D partmek '-NTAL HEALTH <br /> at the top of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) ER, 7A/1 E N T <br /> Alf 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 othen0ise 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 recordslother appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: October 26, 2017 Inspected By: BETTY HO <br /> Facility Address: 975 S FAIRMONT AVE, LODI CERS ID.' 10180611 <br /> 1 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. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH N(IOLATION <br /> and I believe the information to be true,accurate,and complete: <br /> Photos_Paperwork_Statement <br /> 1 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' a A op- �Z17 <br /> r Kle: <br /> Signatu n ,Date: <br /> 1868 E. HAY01ton Avenue Storkton. Californi 1 95205 T '20q 468-3420 F 20,q 464.-0138 www,SiCohd,coin <br />