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*RECEIVED <br /> San Joaquin County MAR 2 7 2017 <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,Califomia 95205-6232 <br /> mal `; Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sinov,utc�Lefmd�oNMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <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 retumed 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date: January 23,2017 Inspected By: Elena Manzo <br /> Facility Address: 2575 COUNTRY CLUB BLVD CERS ID: 10118074 <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 co�mp/let'e::� <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 <br /> and/or irisonment for know violations- (HSC 25191) <br /> Name: i z Ve VN- Title: ��tC,� YIA CA r•G <br /> Signatur Date: L/ r I_ <br />