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Adlik <br /> qW <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, Califomia95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sFaoy.orD/ehd <br /> Hazardous Materials Program Inspection Report <br /> Facility Name: Facility Address: Date: <br /> CHURCHS CHICKEN #5773 8023 WEST LN STOCKTON June 18, 2015 <br /> Complete and submit a copy of the Return to Compliance Certification form to the EHD with a statement <br /> documenting the corrective actions that have been or will be taken for each violation, and any supporting <br /> paperwork, by 7/18/2015 . <br /> Please be aware as of January 1, 2013, all businesses are required to submit all hazardous materials information <br /> online to the California Environmental Reporting System(CERS) at http://cers.calepa.ca.gov. Be sure to include <br /> your hazardous material activity in the Businesses Activities section in CERS in addition to any other relevant <br /> activities and required fields. <br /> ALL EHD STAFF TIME ASSOCIATED WITH FAILING TO COMPLY BY THE ABOVE OTED E:11!!ES WILL BE BILL DAT THE CURRENT HOURLY RATE. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE <br /> Received ByReceived ey(printed name and title): Date: <br /> )signature: Aurora Hernandez, Manager (p— / - /S <br /> Inspector Inspector(printed name and title): Inspector Phone: <br /> (signature): NICHOLAS LOEHRER, HM Specialist 1 (209) 468-0623 <br /> Page 4 of 4 <br />