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,._� <br /> Environmental Health Department <br /> S HN <br /> AOL <br /> �± r,e,7ri +rxsttMx3 ikrs'• <br /> Corrective Action Statement <br /> RE % November 03, 2021 , 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) 616-3063 or stwoldearegay@sjgov.org. <br /> A&A GAS FOOD MART, 1330 E YOSEMITE AVE, CERS ID* 10184191s PRO515864 <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents. <br /> 0 This violation was corrected This violation will be corrected by (date) : �� / � �� <br /> 0 Supporting documents Included <br /> Describe actions taken or will be taken to correct violation : <br /> eon, 400�1 <br /> Violation #109 - Failure to submit "Designated Underground , Storage Tank Operator Identification Form' <br /> within 30 days. <br /> `J N <br /> 0 This violation was corrected Gofhls violation will be corrected by (date): <br /> 0 Supporting documents included <br /> Describe actions taken or will be taken to correct violation : <br /> OhO�c- /s rx/l i f I4 Aoi4 <br /> MINIS <br /> Violation #110 - Failure to submit the "Underground Storage Tank Statement of Understanding and <br /> Compliance Form". <br /> 0 This violation was corrected 90rhIs violation will be corrected by (date): <br /> 0 Supporting documents Included <br /> Describe actions taken or will be taken to correct violation. <br /> v <br /> d-A.I►G //� GOI�.S <br /> Page 3 of 6 <br /> Rw. OHN202p <br /> 1668 E . Hazelton Avenue I Stockton , Califomia 95205 1 T 209 4684420 1 F 209 464-0138 1 www.sjgov.orglEHD <br />