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SAN 10 A Q U I N Environmental Health Department <br /> COUNTY <br /> dQ Greot �� ess grcv; s here . <br /> Corrective Action Statement <br /> RE : February 09 , 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 Vicky Vang-Lee at (209 ) 616-3028 or vvang-lee@sjgov . org . <br /> Facility name : SHOP N GO 3 Submit completed form to: <br /> Facility address : 4511 PACIFIC AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10180943 ATTN : VICKY VANG-LEE <br /> PR0231216 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #104 - Failure to have an approved UST Monitoring Plan . <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 /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents . , <br /> This violation was corrected ❑ This violation will be corrected by (date) : � L� h �-I �� IJP <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : <br /> Violation #109 - Failure to submit " Designated Underground Storage Tank Operator Identification Form " <br /> within 30 days . <br /> f� This violation was corrected ❑ This violation will be corrected by (date) : art <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : <br /> Page 2 of 4 <br /> Rev. 9/16/2020 <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 i www . sjgov . org/EHD <br />