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SAN JDAHIN <br />Environmental Health Department <br />Corrective Action Statement <br />RE: January 21, 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. <br />Also, describe what was done to correct the violation in the space provided below each violation. Submit this <br />completed form with the Return to Compliance Certification within 30 days of inspection. If you have any questions, <br />please contact Paul Nso at (209) 468-3432 or pnso@sjgov.org. <br />Facility name: PACIFIC AVE CHEVRON <br />Facility address: 6633 PACIFIC AVE <br />CERS ID: 19594654 <br />PR0231784 <br />Submit completed form to: <br />SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATTN: PAUL NSO <br />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 />0 Supporting documents included <br />Describe actions taken or will betaken to correct violation: T-I—c <br />Axl Ems. <br />Violation #118 - Failure to submit the "Underground Storage Tank Statement of Understanding and <br />Compliance Form". <br />Rev. 812712019 <br />This violation was corrected 0 This violation will be corrected by (date): <br />0 Supporting documents included <br />Describe actions taken or will be taken to correct violation: e— <br />L [ <br />Page 2 of 4 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0938 1 www_sjcehd.com <br />