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r?7!e% --0 V E b <br /> San Joaquin County <br /> Environmental Health Department OCT 3 0 2014 <br /> 1868 East Hazelton Avenue, Stockton, California 85205-6232 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:myw.sioov.ordehd <br /> r­_nIVIRONMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <br /> Any MINOR violations noted in the"Notice to Comply'in the attached Inspection Report must be corrected within 30 day§of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All corrections to other violation 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 EMD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EMD 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 results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Inspection pate: October 22, 2014 Inspected By: MICHELLE HENRY <br /> Facility Address: 1111E KETTLEMAN LN, LODI EPA IR <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personalty 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 penalties for submitting false information, including the possibility of a fine <br /> and/or im risonment for kno n violations. (HSC 25191) <br /> Name: hi)le � I Title: 10CJ� I�� <br /> Signature: Date: �� <br /> yWM 4111 - T (JILL ASX Th�e P-CLI A09W 9F 7 . S 09M)7 1 F.f; ,eIFS U0T <br /> wrtTt+ � � 30 -2)A-Y <br /> 3TEAA it 124 _ i ll"F M Ad)� f19PD/n1T�f"7 c t of it�t S To �n <br /> �--- C, Aj CSS rDe)"_uk e-jurp d u /1-2 5-2 61(l 9 AA. <br />