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2015-06-17 10:31 W1091 2093667310 >> 2094683433 P 4/9 <br /> San J <br /> rW <br /> scala 95205,W32 <br /> TOA*twe:(209) 20 :( ) W Web..WWAWWQ t <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> receipt aE sWIc <br /> Any MM&violation <br /> In nHotice to Cin ed Inspection Report must be in��. $Of <br /> Insp n. This CertiftstiOn form mint be submitted to the Environmental Heath Department(EHD)address <br /> Itte top of Baia form widtin 30 day of receipt of the Inspectiort Report. HSC 25404.1-2400) <br /> All <br /> Retort(IR)or Continuation Forth,or d s to an <br /> no in ed t y <br /> T ansa are to bet$It ding this cerfiftation and r9Wmed to END VdftXL4W unless oth se in tete <br /> ttS titin Re HSG 25185(c)(3) <br /> NOW i EHD staff*no a**WjSfgd with fallingy the above noted datm will be <br /> billed at the current hourly rate <br /> For this certification to be complete, operator of the site must Include: <br /> A statement documenting correctiveactionsweretaken or will betaken <br /> fareach <br /> vl <br /> olatim <br /> Copies of sample rewb1mandeStWhaining stather apPaperwork,andtor $verifying correctIons <br /> Inspection Date.- May 19 201S I : ARIS V LOSO <br /> Facility : 26180 RE Y-NOLDS RANCH PKWY, Lodi EPA <br /> I 06rW 06r' under penalty of lave that: <br /> 1., I have correct9dthe violations speciWintheIns Report from the abOve-metitioned inspection <br /> date. <br /> 2. l have persorddlytlon sub as ofcompliance' F EACH VIOLATION; <br /> €believe the information to be true,accurate,and cat e-. <br /> -Ph tos Pa <br /> ---e-.--,�.,. pe _Statement <br /> 3. l arta authorized to submit ft Certificaftn on behatf of the Respondesnt. <br /> 4. l am aware that there are solftcant penaes for submittingfalse inIbrmation=Including the POSSIbIfty of a fine ancY <br /> imprisonment for known vkatatloft (NSC 25191) <br /> Name. t" Tits: S. .S . I� 4-, <br /> Signature -, <br />