Laserfiche WebLink
t <br />;b Environmental Health Department <br />Y <br />SAN e]OAQUIN <br />.cs —COUNTY-- <br />RETURN <br />Y —RETURN TO COMPLIANCE CERTIFICATION <br />AnyIM NOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />apartment (EHD) address at <br />receipt of this inspection. This certification form must be submitted to the Environmental Health D <br />the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />Ail 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 />Its billed at the current hourly rate. <br />For this certification to be complete, the operator of the site must Include: <br />nA A statement documenting what corrective actions were taken or will be taken for each violation <br />y . corrections <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br />Operator's certification <br />w ugust 20, 2020 <br />inspection Date: A <br />Inspected By: CLAUDIA MURO <br />CERS ID: 10767370 <br />Facility Address: 209 N Houston LN, LODI <br />C* <br />A. ,i <br />Y. _i 1 certify under penalty of law that: <br />%y 1 <br />"' ; .y <br />;., .,.1 1. I have corrected the violations specified in the Inspection Report from the above mentioned inspection ate. <br />0tion <br />2 a have <br />bel eve the information to bfe true <br />• accurate and complete:!tted as proof of compliance FOR EACH VIOLATIO <br />aA <br />Photos PaperworkZStatement <br />4 ` 3, I am authorized to submit this certification on behali of the Respondent. <br />OiPI,`' 4. I am aware that there are significant penalties for submitting false information, IncVAAVIluding the possibility of a fine and/or <br />n violations. (HSC 25191) <br />imprisonment for know <br />to <br />Title: <br />} Name: Date: ' ^ `X 2 G <br />VIA . <br />Signature: <br />I AI <br />At:I A <br />t, A1: <br />rj <br />{_ <br />l _ J <br />WI <br />Ir <br />k nqp <br />n'T t Ate <br />At <br />VIA <br />viv 111* 4 44 <br />ZZ <br />wk 4;Ar I`t�A AAA <br />Y <br />1 AI <br />>I ate, <br />r <br />_ A. <br />vt , <br />s i..t 1 i .. <br />