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1 Q N ` l 8( � Environmental Health Department <br /> C-40� (.j rill TY <br /> 2 z� <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 <br /> at 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 END 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 <br /> Operator's certification <br /> Inspection Date , June 26 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address , 1111 E KETTLEMAN LN , LODI CERS ID : 10182257 <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 I believe the information to be true, accurate, and complete: <br /> Photospaperwork 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 ) Vii; <br /> Name : ` f /u �J Title : l It l <br /> Signature: , pate; <br /> � � <br /> tie) <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 I F 209 464 -0138 1 www.sjcehd . com <br />