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SAN JOAQUIN Environmental Health Department <br /> S <br /> RETURN TO COMPLIANCE CERTIFICATION <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 /> 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 t <br /> Operator's certification <br /> Inspection Date : September 20 , 2019 Inspected By : SHEWIT WOLDEAREGAY <br /> 3 <br /> Facility Address : 1331 S HAM LN , LODI CERS ID : 10181549 <br /> I certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> f <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the information to be true, accurate, and com <br /> Photos Paperwork �Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> ) <br /> 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or <br /> imprison int for known violations . (HSC 25191 ) <br /> i <br /> Name: Title : o1 je �) P1�� J9 I' <br /> Signature : Date : � r <br /> 40 V <br /> s <br /> xi <br /> �I <br /> L3 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www. sjcehd. com i <br /> i <br />