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i <br /> I <br /> Environmental Health Department <br /> COUNTY <br /> . . ,.. <br /> Corrective Action Statement <br /> f RE : March 30 , 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 /> I completed form with the Return to Compliance Certification within 30 days of inspection. If you have any questions, <br /> please contact Shewit Woldearegay at (209) 468-0216 or stwoldearegay@sjgov. org. <br /> Facility name: COUNTRYSIDE LIQUORS & GAS Submit completed form to: <br /> Facility address: 14971 N HWY 88 SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180623 ATTN : SHEWIT WOLDEAREGAY <br /> PR0231911 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #123 - Failure to submit the "Spill Container Testing Report Form" within 30 days after the test <br /> i <br /> This violation was corrected ❑ This violation will be corrected by (date): <br /> j ❑ Supporting documents included <br /> i <br /> f Describ actions take or will be taken to correct violation : <br /> i <br /> Violation #209 - Failure to conduct the designated UST operator visual inspection at least once every 30 <br /> c <br /> days. <br /> /❑ This violation was corrected ❑ This violation will be corrected by (date): <br /> ❑ Supporting documents included <br /> I <br /> f! Describe actions en or will lie taken to correct vi 1 tion : <br /> I <br /> I <br /> I <br /> I <br /> j <br /> i <br /> f <br /> l <br /> i <br /> i <br /> i <br /> I <br /> i <br /> I <br /> i <br /> i <br /> j Page 2 of 2 <br /> Rev. x/27/2019 <br /> i <br /> 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468-3420 ( F 209 464-0136 1 www. sjcehd .com <br /> j' <br />