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SAN J 0 A Q U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the %lotice to Comply' In the attached Inspection Report must be corrected within 30 days of <br /> racaipt 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 , NSC 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 /> vlolations, arc to be submitted using this certification and returned to EHD W. thin 30 da 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 rosultstmanifestsltralning records/other appropriate paperwork , andror photos verifying corrections <br /> Opor-ator's certification <br /> Inspection Data : May 21 , 2020 Inspected Sy : SHEWIT WOLDEAREGAY <br /> Facility Address : 28$0 REYNOLDS RANCH PKWY , LODI GERS ID : 10146151 <br /> I certify under penatty of law that: <br /> 1 . 1 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 tdua , accurate , and complete: <br /> Photos T Paperwork Statement <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 and/or <br /> Imprisonment for known violations. (HSC 2519 1 ) <br /> Name : CO Title: /tI <br /> Signaturem. /R// _ Date : f A0 le <br />