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• San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California95205-6232 <br /> Telephone.(209)468-3420 Fax: (209)468-3433 Web:www.siqov.oEq/ehd <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 <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.12(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 EHDwithin 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 <br /> billed 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 resultstmanifeststtraining recordslother appropriate paperwork, and/or photos verifying correction! <br /> Inspection Date: April 07 2016 Inspected By: <br /> Facility Address: 1126 E PINE ST LODI EPA ID. <br /> 71have <br /> lty of law that: <br /> cted the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> onally examined the following documentation submitted as proof of compliance FOR EACH VIOLATIO <br /> information to be true, accurate, and complete: <br /> Photos \� Paperwork Y' Statement <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 and/ <br /> imprisonment forkPoWnvi lations. (HSC 25191) <br /> Name: ` Title: <br /> Signature: <br /> Date: <br /> APR 19 2016 <br />