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AUG/18/2021/WED 03; 18 PM Tracy Truck Stop FAX No, 209832 2312 P, 005 <br /> Environmental <br /> Health Department <br /> „i'l lffiY.ldry; <br /> I':I:ii1:::I:..:ioui,..H'�7�::ii 4i'i'�u:,,lli l:•..i.'�'.ii.i::i1:.1.•.�;'.i' '..l::i i'.::i� i.ii'lini''.:i�'.�ii <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 porreQjjons to then 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 EH.D withln 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 /> Operator's certification <br /> Inspection Date: July 19, 2021 In By: CAROL PRESTO <br /> Facility Address. 3940 N TRACY BLVD, TRACY CERS ID: 10182335 <br /> 1 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: r <br /> Photos Paperwork it 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 25191) <br /> Name_ / r»_ "�ILATLP, _Title: t'l'ongO <br /> Signature: rDate:_ �u tr�A ��f� '28 <br /> AUG 18 2021 <br /> ErIVINONMENTA H0\1_1H <br /> PERMIT/SERVICES <br /> I <br /> i <br /> Received Time Aug, 18, 2021 4: 16PM No, 6869 <br />