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IN 0 - 06 - 23 14 : 05 TRACY TRUCK STOP 12098322312 > > P 1 <br /> ; WIP,. � µii;rn%?�ti` ;:: <br /> ` 'tit yn7���IDA Environmental Health Department <br /> . . . <br /> �r�tii� lrirrtTt" ri � 5 �;.: :q,w0 }Ms : :: . jrG' � ti:: <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 r,�fg er vlalarlonG 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 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/tralning records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : April 22 , 2020 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 3940 N TRACY BLVD , TRACY CERS ID : 10182335 <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. I have personally examined the following documentation submitted a$ 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 and/or <br /> Imprisonment for known violations . (HSC 25191 ) <br /> Name 1u c nl 64: Q ..P t� Title : <br /> Signature : � '-� d}� . t� � "R- Date ; C� 2 ' <br /> � 1 P=,P �zo <br /> G0 VN �� p .� Ove J . d, <br /> Pie <br /> CA <br /> l `^ m*I J 0.iv.-CLr ' b'Ik—a, : uf' +�� c9 vt 2:r' OL l ^_� .n ' vv\ -' <br /> h^ OW -o ffPill � \S �e'..w•, C -O f � �� 0. e),, r' ZP, l q 2 "2.0 t "7 r <br /> a( ( c.Nv. � k ..e. - CG 'S qn,v... Ct, � t cti (� l,e a �a_t, Ce<� ? °I 8 3 2 4;P 06 i c lam, <br /> Received Tirne Jun , 23 , 2020 4 : 50PM No , 6046 <br />