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VEB/24/2021/WED 06: 05 PM Tracy Truck Stop FAX No, 209832 2312 P, 001 <br /> ■ <br /> ■■ ■ <br /> ■■ ■ <br /> ■ <br /> Environmental Health Department <br /> N0 ,4 <br /> aA <br /> , Ul <br /> Y. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any[yIINOR 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 o 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 25185(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 Daae: February 09, 2021 Inspected By; PAUL NSO <br /> Facility Address: 3775 N TRACY BLVD, TRACY CERS ID: 10181337 <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 I/• 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 25191) <br /> Name: ��.J Title: sQ <br /> Signature: �. Date: i <br /> FE6 2021 , <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Received Time Feb, 24, 2021 6 : 02PM No, 6614 <br />