Laserfiche WebLink
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.sigov.org/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report must be corrected 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 to other violations 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 within 30 days 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 results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Inspection Date: May 02, 2017 Inspected By: ROBERT LOPEZ <br />Facility Address: 1319 N MADISON ST STOCKTON CERS ID: 10181353 <br />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. ]have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, an 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 <br />and/or im risonment for known violations. (HSC 25191) <br />NameL-5 !C� c , pt (NSy /`i Title: �4c_LL-1—t c��� l V2 EcTU/L <br />Signature J�z�— Date: <br />e/ Z �( 7 <br />n r— <br />Cell-.2O1- 33 -7 -5512 <br />Plymouth Square <br />Independent. Assisted Living & Skilled Nursing <br />Tim Moss <br />RH F <br />www.rhf.org <br />Maintenance & Housekeeping <br />Supervisor <br />1319 North Madison Street <br />Stockton, CA 95202 <br />(209) 466-4341 <br />(209) 466-4756 Fax <br />tim.moss®rhf.org <br />RCFE 390300536 CA A 030000076 <br />A Retirement Housing Foundation Community <br />