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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton,California 9520M232 <br /> To .hone:(209)4683420 Fax:(209)468-3433 web:www.sjgoy.oW/ehd <br /> i <br /> R TURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations note in the'Notice to Comply'in the attached Inspectlon Report must be corrected within 30 days of <br /> receipt of this Inspection. T Is certification form trust be submitted to the Environmental Health Department(EHD)address; <br /> the top of this form within 3Q d of receipt of the lnspeotion Report. HSC 25404.1.2 c 1 <br /> All correatlons tQ other viol ions noted in the attached Inspection Report(IR)or Continuation Form,or dlspQtes to any <br /> violations,are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report HSC 25106(c)(3) <br /> Note: All EHb staq time associated with failing to comply by the above noted dates will be. <br /> billed at the cu kit 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 recordslother appropriate paperwork, and/or photos verifying corredtions <br /> Inspection Date: September 03, 2015 Inspected By: ARTS VELOSO <br /> Facility Address: 13650 N DE VRiES RD, LODI EPA ID: <br /> I certify under penalty of law',that: . <br /> 1 <br /> 1. 1 have corrected the 1 violations specified 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 VIOLATION <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 there are significant penalties for submitting false information,Including the possibility of a fine and/ <br /> Imprisonme r k n viol s. (HSC 2 91) <br /> r <br /> Name: a Title: A L <br /> Signature: Date: <br /> r R'z E.- <br /> SEP <br /> SEP 17 2015 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />