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Parkwood Gas & Food 2098888157 p . 1 <br /> e <br /> Environmental Health Depari .ment <br /> SAN JOnQUIN <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 at <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 251 B5(c) (3) <br /> Note : All EHD staff time associated with failing to comply by the above noted dates will be 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 corrections <br /> Operator's certification <br /> Inspection Date : May 18 , 2021 Inspected By : JOHN ALANIZ <br /> Facility Address : 1612 VV 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 /> and I believe the information to be true, accurate, and complete : <br /> Photos V 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 <br /> and/or imprisonment <br /> tffor <br /> rknown violations . (HSC 25191 ) <br /> Name : S �- \ � W c `� Title : <br /> Signature: -� Date : (0 ' g Z <br /> T7� <br /> a ` <br /> .j t <br /> I FN <br /> Received Time Jun , 8 . 2021 10110AM No , 6161 <br />