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SAN IOAQUIN Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any WOfl violations noted in the 'Notice to Comply" in the attached Inspection Rqmt must be . . of <br />receipt of this inqxdon. This certiricatii form must be submii to the Environmental Health Department (EHD) address at <br />the bottom of this form within 30 days of receipt of the lnbpedion Report. HSC 25404.1.2(~)(1) <br />All . . noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />vblathm, are to be submitted using this mtitication and returned to EHD withfn unb othefwise specified in the <br />Inspection Report. HSC 251 85(c)(3) <br />Nob: All EHD staff time associated with failing to comply by the above noted dabs will be billed <br />at the current hourly rate. <br />For this certification to be complete, the pers st or ofthe ae must M: <br />A statement documemting what corrective adkns were taken or will be taken for each violation - Copieb of sample muItdmanifesMraining recorddother appropriate paperwork, andlor photoa verifying corrections <br />- ~tscerti(icetion <br />Inspection Date: April 26,2021 Inspected By: JOHN ALANIZ <br />FacilSty Add-: 6421 CAPITOL AVE, LODl CERS ID: 101 80605 <br />- - - - - - -- <br />I cedify under penalty of law that: <br />1. 1 have corrected the violations qmdfied in the Inspection Report from the abov8mentioned inswon date. <br />2. 1 have paraonally examined the following documentation submiied as proof of compliance FOR EACH VIOLATION <br />, and I bedii the information to be true, accurate, and complete: <br />X PMOS papenn~rk X Statement <br />3. 1 am authorized to submit this certification on behalf of the Reapondent <br />4. 1 am awam that there are significant penalties for submitting false informetion, including the possibility of a fine <br />and/or imprkm& for knawn violations. (HSC 25191) <br />Haleh Amiri envirnmental Coordinator <br />Name: Tie: <br />Signature: