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SANOAQU � N Environmental Health Department <br /> L� U ' �1 <br /> It � e <br /> t <br /> Corrective Action Statement <br /> RE : March 17 , 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 Woldearegay at (209) 468-0216 or stwoldearegayosigov.org. <br /> Facility name : WATERLOO FOODMART Submit completed form to: <br /> Facility address: 4315 E WATERLOO RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181465 ATTN: SHEWIT WOLDEAREGAY <br /> PR0231760 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #114 - No 0.1 gph annual line integrity test for pressurized piping , or within 30 days after repair. <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 : 118AVE e4%V4 Pz DAga} <br /> Oh 0fl r'*4 Aes4*xY%4A e-o tom. a, o - ten xv, >rep 4vkks <br /> vivo) PIZ> <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 /> 1r rs avAtl��, in 30 <br /> C pIr . To td h a"tjkAr"'j NW � nro ar N av7 <br /> -ex +� to-r,ct % V) oN, t.z uc/'41- <br /> Page 2 of 2 <br /> Rev. 8127/2019 <br /> 1868 E . Hazelton Avenue I Stockton . California 952051 T 209 468L34201 F 209 464 -0138 vAvw. slcehd coni <br />