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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone. (209) 468-3420 Fax: (209)468-3433 Web: _9QW <br />RETURN <br />• COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 dayl of receipt of this Inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSC 25404.1.2(cX1) <br />All gg[MgUgirij to giber vigigtions noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 3Q days <br />unless otherwise specified In the Inspection Report. HSC 25185(c)(3) <br />Note: All EHO 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 <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 9/12/2013 Inspected By*Aris Cacapit <br />-acility Address: 13580 N Devries Rd., Lodi EPA ID#: CAL000292946 <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork -Statement <br />1� <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 <br />possibility of a fine and/or Imprisonment fpr known violations. (HSC 25191) <br />Name: Title: 4-k <br />EHO 22-02-005 Rev 04119/12 <br />