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OCT 12 2021 <br /> ENVIRONMENTAL HEALTH <br /> SAN . JOA 4 U I N Envth% ffi- Vt%TTHealth Department <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 EHD staff time associated with failing to comply by the above noted dates will be billed <br /> 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 : October 12 , 2021 Inspected Sy : SHEWIT WOLDEAREGAY <br /> Facility Address : 2420 W TURNER RD , LODI CERS ID : 10181595 <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 /> Photos PaperworkStatement <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/or imprisonment for known violations . ( HSC 25191 ) <br /> Name . Mra .1� �(X �(? d'�,7� Title : CLA <br /> g l � <br /> Si nature : (' '� Date : <br />