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UG/18/2021/WED 03:17 PM Tracy Truck Stop FAX No,209832 2312 P,001 <br />''��.3!;�,:'��'w!•, i,!�I �.,,.I I'i, is {a: : I; is 'I' . �; :I� L.' <br />w. w <br />Environmental Health E ant <br />f�:�a: �, 'y• :aT' i l�i•l;�jf�• I:..;•:�i�.,l��; .., Vi..l.a;a':I�� ���':;; ii•:;: <br />.'.y:.; �'•.�W'rt.�� ith i�l'1.:.�!'. j' i����1i9:� '/�I1�� ,{ <br />.y�.,a:•',".^'f.�.h`l�.I'Y��,v;�i�i;isi�^i.�:�:::�.:L:IsI:;::;C:���'.j`i;�l:a.l::�;j:a�::�i�fillr:�: <br />i;:'�.;'�:. 4: � 0 11;j;�£'t rl!�•)�T i;:�::��{?17.�f3'!t�;�;�,1; � I 1!7ie[1':'.:,; r.,,l�l <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 (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 corragtions 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 wi hln 30 dans unless otherwise specified in the <br />Inspection Report. NSC 25185(c)(3) <br />Note: All EHD staff time assoclated 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 />Operator's certification <br />Inspection Date: July 19, 2021 Inspected 13y: CAROL PRESTO <br />Facility Address: 394O.N TRACY BLVD, TRACY CERS 1D: 10182335• <br />1 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 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 <br />and/or imprisonment for known violations. (HSC 251 s1) <br />Name: <br />Title: <br />r <br />Signature: Date: <br />AUG 18 2021 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Received Time Aug, 18. 2021 4:16PM No, 6869 <br />