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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telep one:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> CONTINUATION FORM Page: 6 of 6 <br /> OFFICIAL INSPECTION REPORT Date: 11/29/12 <br /> Facility Address: 1901 ountry Club Blvd, Stockton Program: HW <br /> SUMMARY OF VIOLATIONS <br /> CLASS I,CLASS II,or MINOR-Notice to Comply) <br /> Note <br /> 1. By December 29, 2012 send the following to the San Joaquin County Environmental Health <br /> Department-. Return to Compliance Certification form, statement explaining how each violation was <br /> resolved and supporting d cumentation. <br /> 2. CERS ID number for th facility is 10183839. Use this number to access, review and approve data <br /> placed in the CERS syste . Please return the lead user authorization form to the EHD by December <br /> 29, 2012. <br /> ALL EHD STAFF TIME ASSOCIATED WITH FAILING TO COMPLY BY THE ABOVE NOTED DATES WILL BE BILLED AT THE CURRENT HOURLY RATE. <br /> THIS,FACILI_TY IS SUB JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD lnspector: ,� V7R ived By: Title: <br /> �C`Y <br /> �HD 23.02-003 Rev 04/19/12 CONTINUATION FORM <br /> G <br />