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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: www.segov.org/ehd <br />FacilityName: Facility Address: Date: <br />tY <br />VAN DE POL ENT INCIPACIFIC PRIDE 351 N BECKMAN RD, LODI June 25, 201 <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 7-25-15. <br />Please be aware that as of January 1, 2014, facility operators are required to upload the following UST program <br />documents into the California Environmental Reporting System (CERS): UST Monitoring Site Plan, UST <br />Certification of Financial Responsibility, UST Response Plan, UST Letter from Chief Financial Officer(if <br />applicable), and the Owner Statement of Designated Operator Compliance. The UST Owner/Operator: Written <br />Agreement, if applicable, can be stored at the facility or uploaded into CERS. <br />THIS F ILIT IS U TO FIIEINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE <br />Received By Received By (printed name and title): Date: /I <br />(signature): Ted Shackelford, Manager5. rA - <br />G I <br />Inspector Inspector (printed name and title): Inspector Phone: <br />(signature): ARIS VELOSO, Senior REHS (209) 468-3453 <br />Page 5 of 5 <br />