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%M Parkwood Gas & Food 2098888157 p . 1 <br /> RECEIVED <br /> % ` <br /> MAY 302019 <br /> SANO Q ( N Environmental Health Department <br /> N �' IIZONNtEN �i'ikL IIEALI' l-I <br /> DEPAWFNIEN r <br /> RETURN TO COMPLIANCE CERTIFICATION <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 /> the bottom 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 returned 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 , andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 08, 2019 Inspected By: STACY RIVERA <br /> Facility Address : 1612 W HAMMER LN , STOCKTON CERS ID: 10181241 <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 /> I believe the information to be true, accurate, and complete : <br /> Photos Paperwork v 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 and! <br /> imprisonment for known violations. (HSC 25191 ) <br /> Name: \7- eST45 AJ � Title : %� C <br /> Signature: Z2Date: <br /> 1868 E . Hazelton Avenue Stockton , California 95205 j T 209 468 -3420 1 F 209 464 -0138 1 www . sjcehd . com <br /> Received Time May , 30 , 2019 10155AM No . 5076 <br />