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ZSLti ' 0N Wd85A 6GOi, ' l APA ; Wli paAiaaa � <br /> s <br /> IT! <br /> P. Env ' Fe fi ode art , <br /> PIP :,A � P <br /> : . ;= : . <br /> „ A , ; � � . :�<� ,. . � �, _ 2018 <br /> �� 110 <br /> _ : I 1 41 Poll <br /> RC seek' g : G0a �`^ <br /> Idl : 1 10 , 161o`;AN A4 <br /> RETURN TO COMPLIANCE CERTIFICATION DEPARTMENI <br /> Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report must be corrected within 30 dans of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department (EHD) address <br /> at the top 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. H$C 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date. February 22 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address : 633 E VICTOR RD , LODI CERS ID : 10180603 <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 /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true, accurate, and complete: <br /> Photos 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 <br /> and/ imp sonment for known violations, (HSC 25191 ) <br /> Name: Title : <br /> Signatur ' �-- Dater <br /> Poll- <br /> ■}1 <br /> 1868 E. Hazelton Avenue ( Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www,sicehd.com ® ■ <br /> ■ <br /> £ 00 / T00 " d 69tz # b89fib £ £ 60Z T £ : £ T 6TOZ / TO / 4 <br />