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a r <br /> San Joaquin County RECEIVED <br /> Environmental Health Department JUN 2 2 2017 � <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telep one:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/e ,VIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 /> at 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 violatio s noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any <br /> violations, are to be submittedsing this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 2518 c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the curre it hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documents g what corrective actions were taken or will be taken for each violation <br /> Copies of sample resul s/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: June 16, 2017 Inspected By: STACY RIVERA <br /> Facility Address: 1856 COUNTRY CLUB BLVD, STOCKTOI EPA ID: <br /> I 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. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos_Paperwork Statement <br /> 3. 1 am authorized to sub nit this certification on behalf of the Respondent. <br /> 4. 1 am aware that therere significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for know il <br /> violations. (HSC 25191) <br /> Name: Title: ���/A_-P. + Sii-­�AS <br /> Signature: Datej Z( Z .4 <br /> Ivy Z w � V1Do. brd, h« � <br /> 1-eA I v, J <br /> 0 e,,,,% r, Iu y d t5 c e) i 1 h� 6'�uoe �I ' -L{a,r-� 1 v-\ L �g �2 <br /> v g l will �r�pe a� �--e-.e- fir( <br />