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P �A <br /> M ' . Environmental Health Department <br /> S —COUNTY— <br /> Greatness <br /> COUNTY+Gr tress grows here. <br /> RETURN TO COMPLIANCECERTIFICATION <br /> Any I violations In the Notice to Comply"in the attached Inspection Report must be within 30 days of <br /> receipt of this Inspection. This cartificaflon form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of the form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All cxr rrs to noted in the attached* n Report(IR)or Continuation Fonn,.or disputes to any <br /> violations,are to be submitted using this certification tifiration and r6tumed to EHD mdhin 30 dM unless otherwise specified In the <br /> Inspection Report HSC 26185(cX3) <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 coffective actions en or x111 betaken for each violation <br /> Copies of ani raining recordslother appropriate paperwork,and/or photos verifying <br /> -corrections <br /> Operator's certification <br /> Insp onDate: —November 08,2018 Ins By: ZUNA BARKER <br /> Facility Address: 880 E VICTOR RD; LODI CERS ID: 10181491 <br /> .certify under *of law that <br /> 1. I have corrected the violations in the Inspection Report from the above-mentloned iroxedon date. <br /> 2.• 1 have personally examined the following docurrientatim submitted as proof of dompliance FOR EACH VIOLATION <br /> and I believe the Information to be true.accurate,and complete: <br /> _2::::Photose! Paperwork_jz::�_Statemerrt <br /> 3. 1 am authorized to submit this ce0cation on bahaff of the Respondent <br /> 4. 1 am aware that there are significant penalties for subinitting false information,including the possibility of a fine <br /> and/or Imprisonment for know . (HSC 25191) <br /> Na u� rile: 1-�Au A <br /> Signature: Date: I! O 1 <br /> 1 <br /> DPr-,0 4 4 14 <br /> 810E Q X30 <br /> 1868 E.Hazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sjoehd.com <br />