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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> RET RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health D partment(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any violation , are to be submitted using this certtficatton and returned to EHD within 30 days <br /> unless otherwise specifi din the Inspection Report. <br /> Note: All EHD staff tiI a associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rat ($122). <br /> For this Cel`C1f1C tion t0 be Complete the operator of the site must include: <br /> • A statement doc entingg what corrective actions were taken or will be taken for each violation <br /> • Copies of samplD results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Ap rit 11, 2011 Inspected By: Aris Cacapit <br /> Facility Address: 1551 Eight Mile Rd Lodi CA EPA ID#: CAL000360129 <br /> I certify under pena ty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLA ION and 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. I am aware that there are significant penalties for submitting false information,including the <br /> possibili of a me and/or imprisonment for known violations. (HSC 2519 1) <br /> i <br /> Name: ��� " Title: i <br /> Signature: Date: <br /> EHD 22-02-005 Rev 08/10 v\k-m.l A C' -2-1 SO @ �a,hCTO C.o m <br /> t,.��t� c✓' -��4f CE <br /> 2 z <br /> '��- 4,, ( R zz ( w- 12,5 5 l <br />