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SAN J O AQ U i N Environmental Health Department <br /> Corrective Action Statement <br /> RE : May 27, 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@sigov .orq . <br /> Facility name : DBA CIRCLEK , REFUEL PETROLEUM INC . Submit completed form to <br /> Facility address : 419 S MAIN ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181307 ATTN: PAUL NSO <br /> PR0231433 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #103 - Failure to submit and maintain complete and current financial responsibility documents . <br /> Q This 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 /> L )Ar ars , b 70 C4s-,C - <br /> Violation #113 - Failure to submit " Monitoring System Certification Form " within 30 days of completion of the <br /> test. <br /> I$ This 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 /> j SHIT C � �� /� c.tT Wt �L RF oti Tiiy� f /'lzdM Nvr..t � � ,v <br /> I <br /> I <br /> Page 2 of 5 <br /> Rev. 8/2712019 <br /> i <br /> 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468- 3420 i F 209 464 -0138 i www . sjcehd. com <br />