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SAN 10AQUIN Environmental Health Department <br />N I Y <br />Corrective Action Statement <br />RE: May 06, 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. <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) 616-3049 or pnso@sjgov.org. <br />Facility name: <br />Facility address: <br />CERS ID: <br />DBA CIRCLEK, REFUEI PETROLEUM INC. <br />419 S MAIN ST <br />10181307 <br />PR0231433 <br />Submit completed form to: <br />SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATTN: PAUL NSO <br />1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #115 -Failure to submit "Monitoring System Certification Form" within 30 days <br />test. <br />of comp►etion of the <br />This violation was corrected <br />❑ Supporting documents included <br />❑ Thts violation will be corrected by (date): <br />Describe actions taken or will be taken to correct violation: <br />CSD !�44 SSA T'D O,t tqc o i <br />INen do r,•r4p <br />H <br />Violation #122 -Failure to implement corrections and submit written response within 30 days of receiving the <br />reP0rt <br />®. This violation was corrected ®This violation will <br />be corrected by (date): <br />❑ Supporting documents included ,I <br />Describe actions taken or will be taken to correct violation: 7Aal LAo)I TY 14je%; Dd f 1RV,E <br />�.�.._. <br />111..,r crc <br />0.etlnu/ n t{-ava TAtc-f.) IA16y_ Ai AllGf, 1. 1 %le <br />o. <br />N C noZ�u 44 <br />owr �,e�vLau sf.�r,&i <br />Page 2 of 3 <br />Rev. 9�16�2020 <br />1868 E. Hazelton Avenue � Stockton, Catifomia 95205 j T 209 468-3420 � F 209 464-Ot38 j wwwsjyov.org;EHD <br />