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San Joaquin County <br />Environmental Health Department <br />868 East Hazelton Avenue, Stockton, California 95205-6232 <br />me: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in t e "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 violationnoted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted u ing this certification and returned to EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185( )(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 lo 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 result/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Inspection Date: June 04, 2015 <br />Facility Address: 2200 <br />I certify under penalty of law <br />Inspected By: FATINAH ZAREEF <br />UNTRY CLUB BLVD, STOCKTON EPA ID: <br />1. 1 have corrected the violotions specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally exami0ed the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />I believe the information o be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am authorized to subnr it this certification on behalf of the Respondent. <br />4. 1 am aware that there ar significant penalties for submitting false information, including the possibility of a fine a <br />imprisonment for known iolations. (HSC 25191) <br />Name: <br />Signature: <br />)C) y �/ " �� 1 fA <br />Title: OryA)J(R <br />Date: _ I S <br />t_krVAbL(, <br />P v_�D -r-'j k;Ie <br />