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SAN JaQQUIN Environmental Health Department <br /> .. . . C_' r�iUINTY <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 <br /> or will bebelow e corrected ected by Submit this certain e <br /> Also , describe what was done to correct the violation in the space provided <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 /> ATTN: PAUL NSO <br /> CERS ID : 10181307 1868 E HAZELTON AVENUE <br /> PR0231433 STOCKTON , CA 95205 <br /> Violation #103 - Failure to submit and maintain complete and current financial responsibility documents . <br /> 14 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 /> Violation #113 - Failure to submit " Monitoring system Certification Form" within 30 days of completion of the <br /> test. <br /> ra 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 /> s >~iJi L � � rtT c � d� j,;420M Nam <br /> Page 2 of 5 <br /> Rev. 8/27!2079 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468- 3420 F 209 464-0138 i www. sjcehd. com <br />