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SAN = JOAQUIN Environmental Health Department <br /> C_ C) UNTY <br /> Corrective Action Statement <br /> RE : September 23, 2019 , 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 phso@sjgov. org . <br /> Facility name : EI Dorado Food Mart Submit completed form to: <br /> Facility address : 1901 S EL DORADO ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10180839 ATTN: PAUL NSO <br /> PR0231092 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #103 - Failure to submit and maintain complete and current financial responsibility documents . <br /> OoonThis 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 /> TN iS / /JFyjZM ,8770 *^ J wg 5 Sy1RA117 b AeV e ee�tz5 75 <br /> Violation #113 - Failure to submit " Monitoring System Certification Form " within 30 days of completion of the <br /> test . <br /> EIis violation was corrected ❑ This violation will be corrected by ( date ) : <br /> Supporting documents included 1 , <br /> Describe actions taken or will be taken to correct violation : ✓►'1 DN 1 T 09/ . 1i2-T Ft •S��/� <br /> �r <br /> i <br /> Page 2 of 6 <br /> Rev. 8127/2019 <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468 -3420 1 F 209 464 -0138 1 www . sjcehd. com <br />