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SANJOAQUI Environmental Health Department <br />COUNTY <br />t�c,v Greatness grows here. <br />Corrective Action Statement <br />RE: July 27, 2020, Underground Storage Tank inspection report <br />For each violation listed below, indicate if the violation has been corrected or will be corrected by a certain date. Also, <br />describe what was done to correct the violation in the space provided below each violation. Submit this completed form <br />with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please contact <br />Shewit WoldearegaV at (209) 468-0216 or stwoldearegay(d).sjgov.orq. <br />Facility name: H&M - BW #98 Submit completed form to: <br />Facility address: 2501 JACKSON AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />CERS ID: 10181511 ATTN: SHEWIT WOLDEAREGAY <br />PR0231488 1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #103 - Failure to submit and maintain complete and current financial responsibility documents. <br />❑ This violation was corrected ❑ This violation will be corrected by (date): <br />❑ Supporting documents included <br />Describe actions taken or will be taken to correct violation: <br />Violation #201 - Failure to maintain monitoring, maintenance, and follow up action records. <br />❑ This violation was corrected ❑ This violation will be corrected by (date): <br />❑ Supporting documents included <br />Describe actions taken or will be taken to correct violation: <br />Violation #209 - Failure to conduct the designated UST operator visual inspection at least once every 30 <br />days. <br />❑ This violation was corrected ❑ This violation will be corrected by (date): <br />❑ Supporting documents included <br />Describe actions taken or will be taken to correct violation: <br />Page 2 of 3 <br />Rev. 8/27/2019 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />