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.AUG/17/2021ME 02,20 PM Tracy Truck Stop FAX No,209832 2312 <br />U�� 2oq 4fo� n(3� <br />P, <br />Date: <br />001 <br />IEnvirenmental Health Department <br />RETURN TO COIVIPLIA,NCE 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 (END) 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 .�yithln 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, and/or photos verifying corrections <br />Op®ratar's certification <br />Inspection Date: June 28, 2021 Inspected By; CAROL PRESTO <br />Facility Address: 7501 W ELEVENTH ST, Tracy CERS ID: 10509463 <br />I certify under penalty of law that: <br />1. I 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.Paperwork L�� <br />Statement <br />3• 1 am authorized to submit this certification on behalf <br />of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, inGuding the possibility of a fine <br />and/or' imprisonment for known violations. (HSC 25191) <br />Name: iN� k%\l , r�\ ) ,t <br />rt,_ '^{ ,-.s-��•� :,, �, <br />Title: _ •.-��.�: T <br />Signatu <br />Received Time Aug, 11. 2021 3:19PM No, 6863 <br />14:�'rl�)t L Iti�At�rl� <br />tYrM►.N <br />rc J <br />