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12/12/2017 3:49 Pill FAX 2093394287 FLYNG J LODI CA <br />SAN MA OU I N Environme <br />RETURN TO COMPLIAWCE CERTIFICAI <br />Any M OR violations noted in the 'Notice to Comply" in the attached Inspection Report must be cc <br />receipt of this inspection. This Xrtifrca6on form must be submitted to the Environmental Health Der <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1,2(c)(1) <br />All correctio toof er viol tions noted in the attached Inspection Rem rt (IR) or Continuation Form, <br />violations, are to be submitted ( sing this certification and returned to EHD 49 L 30 days unless oth <br />Inspection Report HSC 25185-c)(3) <br />Note: All EHD staff time associated with falling to cotly by the above noted <br />billed at the curre'11t hourly rate. <br />100006/0008 <br />I Health Department <br />vlLhin 30 days of <br />(EHD) address <br />disputes to any <br />vise specified in the <br />will be <br />For this certification to be complete, the operator of the site must include: <br />A statement documenting what corrective actions were tekeipr will be taken for each vlolati <br />On <br />Copies of sample resu Is/manifests/training records/other appropriate paperwork, and/or pric tl s verifying <br />corrections <br />Operator's certification <br />Inspection Date: Dec mbe:r 07, 2017 Inspected Ely: <br />Facility Address: 152 l7 N Thornton Rd, Lodi CEF5 ID: <br />I certify under penalty of law thin <br />ON HANG <br />10184349 <br />tr <br />1, 1 have corrected the violations specified in the Inspection Report from the above-mentioned i I spection date. <br />2. 1 have personally exan lined the following documentation submitted as proof of complience F OR EACH VIOLATION <br />and I believe the Inforrr ation to be true, accurate, and compt to: <br />Photos _X�aperwork Statement <br />3. I am authorized to sub nit this certification on behalf of the.Respondent, <br />4, 1 am aware that there ;, re significant penalties for submitting, false infonnatlon, including the eslbility of a fine <br />and/or imprisonment fo known violations. (HSC 25191) tr <br />Name: So e �� or, Title: <br />Signature: te: / -L <br />it <br />1868 E. Hazelton A., enue I Stockton, California 95205 I T 209 468-3420 I F 209 <br />QF <br />I www.sicehd.coni <br />