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SAN 10AQUiN Environmental Health Department <br /> COU N" Y <br /> Corrective Action Statement <br /> RE: September 07, 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, descnbe 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 Vicky Vang-Lee at(209)616-3028 or Wang-lee@sjgov.org. <br /> Facility name: SHORT STOP FOOD MART Submit completed form to: <br /> Facility address: 20 W TURNER RD#A SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> ATTN:VICKY VANG-LEE <br /> CERS ID: 10180633 1868 E HAZELTON AVENUE <br /> PR0231380 STOCKTON,CA 95205 <br /> Violation#117-Failed to submit"Secondary Containment Testing Report Form"within 30 days after the test. <br /> This violation was corrected ❑This violation will be corrected by(date): <br /> ❑ Supporting documents included <br /> Describe a tions takeii or will be taken to correct violation: <br /> 1 <br /> W� <br /> Violation#122-Failure to implement corrections and submit written response within 30 days of receiving the <br /> report. <br /> ❑ 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 /> - 1 <br /> Violation#208-Failure to comply with the designated operator inspection requirements. <br /> This violation was corrected ❑This violation will be corrected by(date): <br /> ❑ Supporting documents included 1 <br /> Describe action taken or w it be taken to co rect violation: <br /> aVU <br /> Page 2 of 3 <br /> Rev gl16r2020 <br /> 1868 E.Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www sjgov org/EHD <br />