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SAN 10A U1 Environmental Health Department <br /> 0 1U N 1- 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 farm within 30 clays of receipt of the Inspection Report HSC 25404 1 . ?_ (c) ( 1 ) <br /> All corrections to other violations rated in the attacfied Inspection Report ( IR} or Continuation Farm , or d [sputes to any <br /> violations , are to be submitted using this certification and returned to EHD within 30 days unless othenmse specified in the <br /> Inspection Report . HSC 251 85(c) ( 3} <br /> Note : All EHD staff time associated with tailing to comply by the above noted dates will be <br /> billed at the current hourly rate . <br /> ror this certification to be complete , the. operator of the site must include <br /> A statement documenting what coi )ctive actions were taken or will be taken for each violation <br /> Copies of sample resultslrTlarlifc;stslfraininc} record slotht;r appropriate paperwork, and/or photos verifying corrections <br /> Operator' s certification <br /> hispection Date : March 26 , 2p24 Inspected By : MARIA LOPEZ <br /> Facility Address : 1301 1N KETTLEMAN LN , LODI CERS ID -. 101 $0585 <br /> I certify under penalty of law that : <br /> 1 I have corrected the violations specified in the Inspection [Report from the above-jneantiflned inspection date - <br /> 2 I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and t believe, the informatior7 to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3 I am authorized to submit this certification on behalf of the Respondent <br /> 4 1 am aware that thea are significant penalties for submitting false information , including the possibility of a filli: <br /> and/or imprisonment for known 0'olatians . (fisc 25191 ) <br /> Tithe : ! " 1 O� <br /> Name �� a <br /> Signature : Date , <br /> �_ --- -- <br /> y .._ Yom.._; •__z'.. -...._ .- - . -:a ' .�,�,st`ae c�w. <br />