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JUN. 9. 2010 4: 18PM LEPPINO PRODJCTION OFFICE N0. 65 P. 2 <br /> • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.(209)468-3420 Fax:(209)468.3433 Web:www.sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <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/manffests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: rJ Inspected By: l QIP ryC� <br /> Facility Address: �C2C�Ir ��IIAYVr . EPAim:0PTL—MOU45-3R <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION 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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) n <br /> Name: 1�02�[ �L <br /> Title:, G <br /> Signature: Date: g <br /> EHD 22-02-005 Rev 10/09 <br />