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• r <br />• <br />;s <br />SANS> OAQUIN <br />---COUNTY------ <br />a <br />—COUNTY —-- <br />Environmental Health Department <br />R <br />-\' ETURN TO COMPLIANCE CERTIFICATIONAl <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 at <br />the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br />,9 <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />at aviolations, 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 />add.For this certification to be complete, the operator of the site must include: <br />A statement documenting what corrective actions were taken or will betaken for each violation <br />ate paperwork, and/or photos verifying <br />- .�. ! Copies of sample results/manifests/training records/other appropri <br />corrections <br />Operator's certification <br />Far <br />t' Inspection Date: addAugust 20, 2020 <br />Inspected By: CLAUDIA MURO <br />admat <br />;: CERSID: 10767370 <br />Facility Address: 209 N Houston LN, LODI <br />daAd1 <br />I certify under penalty of law that: <br />\.� r `,i <br />r -;y <br />\ . ., fi 1. I have corrected the violations specified in the Inspection Report from the above mentioned inspection a e. <br />I <br />2. I have personally examined the following documentation submitted as proof of compliance FOR EAt;H VIOLATIO <br />a M. Fadand 1 believe the information to be true, accurate, and complete: <br />mac! Photos Paperwork .0tatement <br />A <br />-i <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />;_ <br />Fxl4. I am aware that there are significant penalties for submitting false information, Including the possibility of a fine an or <br />da. ag-IFIFF I IF V IF pYI'm4' imprisonment for knowna. <br />violations. (HSC 25191) <br />1 Title: <br />` Name: `qd- <br />IF <br />Date: <br />Signature: <br />ad IF 1 11IF OF Adddrt <br />IF data <br />P.FI a <br />IF <br />r` ,. <br />I ad <br />{s <br />1 <br />Far <br />add <br />ra IF <br />4 1 1t add IF <br />Ad .1 1 <br />-�' <br />ak n wtay; tijVFri _ . . <br />' a ' <br />�' <br />F Ad AtadFd�pad <br />r <br />vc ai YA do <br />a "i <br />I a I IT F a a Wd 16 a a/ <br />��IF <br />fi t IF er - . <br />t r- a .. <br />a III. <br />y a .,t <br />