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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, StocktonCalifomia95205-623 <br />,2 <br /># <br />All 2goglons tQ 91her violations noted in the attached Inspection Report (IR) or Continuation Form. »»..<m to any <br />violation«>e4 be submitted w»«»< cation and retumed to EHDWjih_in_30 d4ys unlessotherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />T R7 M <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(manifeststtraining recordslother appropriate paperwork, and/or photos verifying correction., <br />Inspection Date: May _1 1 2016 Inspected By* FATINAH ZAREEF <br />FacilityAddresm 1403 W COUNTRY CLUB BLVD. 2TOCKT01 EPA <br />M <br />4�31111TIUJITTM UM = 1111 11111111 pIj,;p;I I <br />�iiii ;;111111 M 11 �' IM -1 <br />2. 1 have personally examined the following documentation submitted as Proof Of CGMPIiance FOR EACH VIOLA <br />I <br />:c. ». Infortnation to be true, accurate, and complete: <br />Photos'© Paperwork -statement <br />111 1!111!111!1!11! 111 11!, pj� <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine an;-' <br />imprisonment for kno.,w.» .» ©: <br />Narne- og4o;al Title: V0 AAJ.� <br />Signature-- Date , <br />