Laserfiche WebLink
{ <br /> Environmental Health Department <br /> SAN I O Q Q U I N <br /> C: UUNTY <br /> Greotness yrcws here <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 EMD 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 <br /> Operator's certification <br /> Inspection Date : August 21 , 2019 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 13850 N DE VRIES RD , LODI CERS ID : 10181479 <br /> I certify under penalty of law that: <br /> It I 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 and <br /> 1 believe the information to be true , accurate , and complete : <br /> Photos 7L.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 25191 ) <br /> Name : ! " o Title : ri <br /> Jill , 11; 11111 <br /> Signature : 11 Date : <br /> 1868 E . Hazelton Avenue l Stockton , California 95205 I T 209 468-3420 I F 209 464111,0138 1 www. sjcehd .com <br />