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03/29/2002 19:47 2093397651 LW MTC SHOP PAGE 01/01 <br /> San Joaquin Courft Li <br /> Snvirortmental Health Department <br /> 1868 East Hazalton Avenue,Stockton,California 95206-6232 NOV 0 12016 <br /> Telephone:(209)468-3420 Fim.(209)468-3433 Web:vmw.sjgov.oMMd <br /> RETURN TO COMPLIANCE CERTIFICATION ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 <br /> at the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All oorrectIonLjg_o_tbff.XLo�n 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 EHO staff time associated with failing to comply by the above no dates vAll 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 resultstmenifests/training recordslother appropriate paperwork, and/or photos verifying <br /> corrections <br /> Inspection Date: October 06, 2016 Inspected By: FATINAH ZAREEF <br /> Facility Address: 975 S FAIRMONT AVE, LODI CERSID: 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 VIOLATION <br /> and I believe the Information to be true,accurate,and complete: <br /> Photos Paperwork_$tatement <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 /> .0 1. <br /> Name:- r11— Title: <br /> Signature/' -2/ Date: <br /> 0-5 <br /> C_ d aq <br /> ve, S <br /> 74A Ca 7"0 5dr- 1' 4 deq t-0 0-A,1-5ho <br />