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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />rFacilitye: Facility Address: Date: <br />5446 1403 W COUNTRY CLUB BLVD STOCKTON Ma 12 2015 <br />te and submit a copy of the Return to Compliance Certification form to the EHD with a statement <br />documenting the corrective actions that have been or will be taken for each violation, and any supporting <br />paperwork, by June 16, 2015 . <br />Please be aware that as of January 1, 2014, facility operators are required to upload the following UST program <br />documents into the California Environmental Reporting System (CERS): UST Monitoring Site Plan, UST <br />Certification of Financial Responsibility, UST Response Plan, UST Letter from Chief Financial Officer(if <br />applicable), and the Owner Statement of Designated Operator Compliance. The UST Owner/Operator: Written <br />Agreement, if applicable, can be stored at the facility or uploaded into CERS. <br />Notes: <br />*Verified all sensors at lowest point. <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 FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHUS CURRENT HOURLY RATE <br />Received By <br />Received By (printed name and title): <br />Date: <br />(signature): <br />Panhia Vue, Store Manager <br />6 /,) / S <br />Inspector <br />Inspector (printed name and title): <br />Inspector Phone: <br />(signature): -saw, <br />FATINAH ZAREEF, REHS <br />(209) 953-7311 <br />Page 5 of 5 <br />