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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />r-iq l�� 11 r <br />A:41:4111111 <br />IM. MM, 261-11101W. <br />W 11 W Q I <br />LINTZ 0 ERG40101 W-RIOMM"r-'s <br />I&- <br />A <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 />Inspection Date: November 15, 2018 Inspected By: STACY RIVERA <br />Facility Address: 1725 ACKERMAN DR, LODI CERS ID: 1018138.2 <br />I I I I I I I♦ !I I I : I I I! I I I I I I I I I ! I I I I I I III I � 11 1 1 0 a # <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />I believe the information to be true, accurate, and complete: <br />Photos Paperwork 4 Statemen! <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine awk <br />imprisonment for known violations. (HSC 25191) <br />Name: te <br />Title: <br />Signature: Date: <br />%i? wir" 07-- 'M <br />Ar <br />rb <br />