Laserfiche WebLink
0.11812@16, 11:58 209.3h 06 LODI PACK & SH16P�,r. 0-0 <br /> �E <br /> San Joaquin County <br /> Environmental Health Department i <br /> 1868 East Hazelton Avenue, Stockton, CalifOrnia95205-6232 <br /> Telephone:(2119)468-3420 Fax:(209)468-3433 Web:wwvv.s' ov.or lehd <br /> RETURN TO COMPLIANCECERTIFICATION <br /> Any MIiV(]R violations noted in thB°Notice to Corn <br /> receipt of this inspection. This Certification form must be submitted to the EnvironMent21 Health pe <br /> P}�'in the attached inspection Report must be corrected wi#bin 30 da sot <br /> the tap of this fal7n witnin30 days of recelp#of the Inspe�ian Report. HSC 254D4.fi.2(c)(i) <br /> partmen#(AHD) address <br /> All corrections to other violatlons noted In the attached Inspectlon Report(JR) nr Continuation Form, or dis <br /> violations, are to be submitted using this certifiCatiorl and returned to EMowithin 3c] d auto rythef r,�ise sp�cifieti in <br /> Inspection Repoli, 1 ISC 251 B5 c 3 Pates tri any <br /> { )� ) the <br /> Note: All EHD staff time associated with failing to com l �, <br /> R Y y the above noted dates will be <br /> billed at the current hourly rate. <br /> Fir th lS 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/manifesrts(tralning records(o#her appropriate paperwork, and/or photos velifying correction: <br /> Inspection Date: Apr; ;a ?C-,r; <br /> Facility --� Inspected By: El.-EP-,'A (vj,;j,Zr, <br /> Y Address; 494 4S �,�y 99 S?�} <br /> EPA ll� CAL000265293 <br /> I certify under penalty of iarwthaa: <br /> 1- 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> lly <br /> 2. t have fsthe information <br /> ex on to ti the r foilpwing docur)lentation submitt€rd ss firoof of wrnpiianae FQI�EACH VIOLATiO <br /> believe the information to be true, a.Gwrate, and complete: <br /> Photos xPaperwork _Statement <br /> 3. i.am authorized to submit this certification oro behalf of the Respondent. <br /> 4- lam aware that there are significant pertalties for submitting false information <br /> imprisonment for known violations_ (HSC 25191) , including the Passibility of a tide and! <br /> Name- Stephen Boyd Tilde: Rg, Gasoline Env. Comp Mgr. <br /> Signature.- ^ bate: 5/13/2016 <br />