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®■® Parkwood Gas & Food 2098888157 p . 1 <br /> a■■ <br /> ■ ■ <br /> ■ <br /> SAN 10 A Q U ( 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 30 days of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD ) address <br /> at 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 /> Mote : All EHD staff time associated with flailing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For th is 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/manifestsitraining recordsiother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: June 19 , 2019 Inspected By : ZONA BARKER <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 date. <br /> 2 . I 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 complete: <br /> Photos Paperwork Statement <br /> 3 . I 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/or <br /> imprisonment for known violations . ( HSG 25191 ) <br /> Name: V PSS- UJ rj+iiC� Title : y '� cj 41tC <br /> Signature.� Date : �7 <br /> RECEIVED <br /> JUL 19 20119 <br /> ENVIRONMENTAL HEALTH <br /> DEI'ARTN1ENT <br /> 1868 E . Hazelton Avenue l Stockton , California 95205 j T 209 468-3420 1 F 209 464-0138 www . sjce Ind . corn <br /> Received Time Ju1 . 15 , 2019 9 : 52AM No . 5259 <br />