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San Joaquin County RECEIVED <br /> Environmental Health Department JUN 2 2 2017 <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.slgov.org/ehd. <br /> �NVIROPIMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION PERMIT/SERVICES <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 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: June 16, 2017 Inspected By: STACY RIVERA <br /> Facility Address: 1856W 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 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 and/ <br /> imprisonment for known violations. (HSC 25191) <br /> Name: • ar ind-,p/'" -ct 4 Title: i J"I"j Si i�v+"63 of tkwo <br /> Signature: Date: )UV\-,,O - 1- 1 10 14 <br /> O ( ; w t i +rv,o 6 Fe r-cl1-E L-' ;i-d ut A US + }7�'-� rh i+ <br /> 10 Tj ;' [_09cK4v. Sys �3 a Pc���e� I C�Fr� - L��,� �z+eC+moi- <br /> L> . , jI �. qj �� rk] 5e/-5 c.Ddri-Fe.� <br /> nnu✓�r�;_ <br /> i V p w It PGI A 4-ej Se r3 I A �i �^^ w r� ci r I G It y 4 i--A � <br /> TOrJ�i- <br /> I ?cesur ,vn 11 -le <br /> 1S-r j I, <br /> zG 1 o 'Y LU i, +�,,,� 11 ���LIs �� Sig e ,- ye J, <br /> �ok '� .� w �� � �.�.�e � c� �,r.«� �'�e��„ � o�q.�� cl.� �'i� �" l���i;l k5 i•� <br />