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San Joaquin County <br /> Environmental Heath Department <br /> 1868 East tiazelton Avenue, Stockton, Califomia 952OM232 <br /> Telaphom f2091)4r38-3420 Fax:(209) 468-3433 Web, MM%s9-0v.oro;ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any i�.tN_QR violations noted in the"Notice to Compty' in Vie attached Inspection Report must be corrected within 30 cf <br /> receipt of this inspection This certification form must be su0mittacl to the Environmental Health. Department(EHL?)adtress <br /> at the top Of thIS form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All corrjKdoRs_t+_ott'er vlalatiors noted in the att3ch$cJ Inspectiim Report(IR)or Continuation Form or disputes to any <br /> violahons, are to to submitted using this certification and returned to EHID within 34 da`unless a,herw to spot-fied 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 gate. <br /> For this certification to be complete, the operator of the site must include <br /> A statement docurnentkng what corrertwe actions were takers or wilt be taken for each violabon <br /> Copies of sample resauWmanifeststtraining recorrdslother appropriate paperwork, anWor photos verifying eorrecticris <br /> Inspection Date: March 16, 2017 Inspected By: VICKI MCCARTNEY <br /> Facility Address: 9,649 EMBARGADERO OR, STDCKI'ON CERS ID: 1( 181463 <br /> I certify under penalty of law that <br /> 1 1 have corrected the vooMons specified In the Inspection Report from the above•rnent ones inspection date. <br /> 2 1 have personally examined tete fotlowing documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I belseve the information to be true, accurate, and compteto. <br /> Elhotos ?<- Paperwafk ,� Statement <br /> 3. 1 am suftraed to suumit this certification on behalf of the Responclent. <br /> 4. 1 am aware that there are significant penalties,for submitting fad information, including the possibility of a fine anter <br /> imprisonment for known violations. (HSC 25191) <br /> Name. <br /> Signature; - Date: /Z)- <br /> RECEIVED <br /> UR 2 12017 <br /> alftk ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />