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4+ri'GdUVISS growfi rtcf'O <br />Environmental Health Department <br />Corrective Action Statement <br />RE: June 21, 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: HARNEY LANE AM PM <br />Submit completed form to: <br />Facility address: 255 E Harney Ln SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />CERS ID: 10484500 ATTN: VICKY VANG-LEE <br />PR0537549 1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <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): <br />❑ Supporting documents included <br />Describe actions taken or will be taken to correct violation: <br />12-5' <br />%ylOw �i(Jd� S <br />Violation #110 -Failure to submit the "Underground Storage Tank Statement of Understanding and <br />Compliance Form". <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 />Or-�/'� /e re � a -ti' d s'r✓bw�� ter-¢ � <br />Page 2 of 4 <br />Rev. 9/16/2020 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjgov.org/EHD <br />