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S Q N Q Q u N Environmental Health Department <br /> rI t COUNTY MAIC <br /> `� ,' rtat �fz4 c oars �pere , 31 2022 <br /> VIRONMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION ) r - RMIT/SERVICES <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 : March 02 , 2022 Inspected Bye VICKY VAN & LEE <br /> Facility Address : 302 N CHEROKEE LN , LODI CERS ID : 10182371 <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 _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 penaities for submitting false information , including the possibility of a fire <br /> and/or imprisonment for known violations . ( HSC 25191 ) <br /> Name : *�DewuIS (ILA a rk-cAK>jnli,, Title : <br /> Signature : Date : ✓/0'�5 /aoO <br />