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■v Parkwood Gas& Food 2098888157 p.1 <br /> ■ <br /> ■ <br /> ■ <br /> SAN 10 A W N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within-= ) days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHI:I;,address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report HSC 25404-12(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes tc any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise speciflo i 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 >e billed <br /> 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 c xrections <br /> Operator's certification <br /> Inspection Date: June 17, 2020 Inspected By: PAUL NSO <br /> Facility Address: 1210 E HAMMER LN, STOCKTON CERS ID: 10181355 <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 a s :e. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH'q IOLATION <br /> 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 possibility cf a fine <br /> and/or imprisonment for known violations- (HSC 25191) <br /> Name: eSS-e �-J M 4 Title: Ci- .n�^ _. <br /> Signatur --Z_ Date: - 3 y - -2 _ <br /> RECEIVED <br /> JUL 01 2020 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Received Time Jul, 1. 2020 9: 03AM No, 6070 <br />