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ECFSan Joaquin County IVEU <br /> Environmental Health Department OCT 21 2015 <br /> 1860 East Hazelton Avenue, Stockton,California 85205.6232 <br /> Telephone:(208)468-3420 Fax:(208)466-3439 web: aigov.ora/ehd CNVIRONMENTAI_ <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be QQMaL sd 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(o other v atbns 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 EHD)0hin 30 dave 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 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 resullahllanlfestskraining recwrdstather appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: October 09, 2015 Inspected By: ARIS VELOSO <br /> Facility Address: 1111E KETTLEMAN LN LORI EPA ID: <br /> t certify under penalty of law that <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned Inspection date, <br /> 2. 1 have personally examined the following documentation submittad as proof of compliance FOR EACH VIOLATION <br /> I believe the information to be true,accurate, and complete: <br /> Photos ✓ Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. i <br /> 4. I am aware that there are significant penalties for submitting false information, Including the possibility of a fine and/ <br /> impneoQment for known violations, (HSC 5"" <br /> Name: Ja r'^ Title: 6W <br /> Signature: Date: f o /2-1 12.0 r S <br /> i <br /> i <br />