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SAN J n h Q I I N Environmental Health Department <br /> �l I .y <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 /> Ail 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 25165(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 resultslmanifestsltraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: January 24, 2022 Inspected By: LYDIA BAKER <br /> Facility Address: 530 VV LODI AVE, LODI CERS ID: 10180587 <br /> 1 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. f 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 _Paperwork_ X statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4- 1 am aware that there are . nificant penalties for submitting false information,including the possibility of a fine <br /> and/or i:rDprisonment for own iolations (HSC 25191) <br /> Name: Title: <br /> # <br /> Signature: Date: ! �� <br />