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San Joaquin County <br />Environmental Health Departmeni <br />1 8 Fast Hazelton Avenue, Stockton, California 95205-6232 <br />Telepho e: (209) 468-3420 Fax: (209) 468-3433 Web: www sjgov org/ehd <br />RETURNTO COMPLIANCE CERTWICATION <br />Any MINOR violations noted in th "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 25404.1.2(c)(1) <br />All corrections to other violations oted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted usi g this certification and returned to EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c (3) <br />Mote: 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 be complete, the operator of the site must include: <br />A statement documentin what corrective aciions 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 />Inspection Date: May 05[ 2015 <br />Facility Address: 39 N Cl <br />I certify under penalty of law that: <br />1. 1 have corrected the viol <br />FF AVE. LODI <br />Inspected By: ARIS VELOSO <br />EPA ID:—C A L0 C 03G- k`3-yC% <br />s specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally exami ed the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />I believe the information be true, accurate, and complete. <br />i <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 ar6 significant penalties for submitting false information, including the possibility of a fine <br />imprisonment for known violations. (HSC 25191) <br />Name: 13 r C-- �- �E: �7 �: � � , Title: _ r t r <br />Signature; / - �) Date: U r -I I <br />