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9 0 <br /> 05/13/2015 2:28 PH FAX 12093394287 FLYING J LODI CA. 160005/0006 <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,California 95206-45232 <br /> Telephone, (209)468-3420 Fax:(209)468-3433 Web. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQB violations noted in the"Notice to Comply"in the abChed Inspection Report must be rQMR2UKLwj2jjaZ daym of <br /> receipt of this Inspection. This certification form must be submitted to the Environmental Health Department(151-10)address; <br /> the top of this form within 30 days of receipt of the Inspection Report HSC 26404,12(c)(1) <br /> All corrections to sdhgr yLQlatjgM 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 EHDw. -ithin 3Q Oalm 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 da te$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 resuWmanifests/training records/other appropriate paperwork,and/or photQs verifying corrections <br /> Inspection Date: May 13, 2015 Inspected By: ARIS VELOSO <br /> Facility Address: 15237 N THORNTON RD, LODI EPA ID, aj4Cj'j') <br /> I certify under penalty of low that <br /> 1. 1 have corrected the violations speeffied in the Inspection Report from the above-mentioned inspection date, <br /> 2, 1 have personally examined the following documentation submitted as proof of compliance FOR EACH\AOLATION <br /> 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 them are significant Penalties for submitting false information,including the possibility of a fine and/ <br /> imprisonment for known violations. (HSC 28191) <br /> -1.)o <br /> Name:- <br /> "7- a , <br /> Titie: 5y- <br /> /Z-:� <br /> Signature: Date:I-/ - ,'/// '/ J <br /> 7 <br /> :teaE— CEIVE' 'I") <br /> JUN 12 2015 <br /> ENVINONMENTA, <br />