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SANa10AQUIN Environmental Health ® epadellrrit coir <br /> CQUNTY <br /> Corrective Action Statement <br /> RE : October 25 , 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 . 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 stwoldearegay@sigov. org . <br /> Facility name: Super Store Industries - Grocery Division Submit completed form to: <br /> Facility address : 16888 McKinley Ave SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10166883 ATTN : SHEWIT WOLDEAREGAY <br /> PR0232523 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <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 11fo�rr will be taken to �correct violation :Awl ��•fl1 VQ, 1�QC 1� / � (/� /] �Jj1 " /) <br /> 1•./ ' 1 / 0 1 l.il�/ 1 1 +& FYI I / 1ti/ / �..C.i/ i l ) ! L V t a ( M. 1 Y e <br /> Page 2 of 2 <br /> Rev. 8/2712019 <br /> 1868 E . Hazelton Avenue i Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www, sjcehd . com <br />