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SAN 10 AQ O I N Environmental Health Department <br /> J N 1' Y <br /> Corrective Action Statement <br /> RE: October 27, 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. Also, <br /> describe what was done to correct the violation in the space provided below each violation. Submit this completed <br /> form with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please <br /> contact Carol Presto at(209)616-3061 or cpresto@sjgov.org. <br /> Super Store Industries -Grocery Division, 16888 McKinley Ave, CERS ID: 10166883, PR0232 <br /> Violation#116-Failure to submit the"Spill Container Testing Report Form"within 30 days. <br /> This violation was corrected ❑ This violation will be corrected by(date): <br /> Supporting documents included <br /> onj <br /> Describe actions takeq or will be taken to correct vi lation <br /> , f ' A <br /> Q)-12,00fm VM 4b <br /> Page 3 of 3 <br /> Rev 91161202C <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 />