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S A WA A Q U IN Environmental Health Department <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 /> Facility name: Super Store Industries-Grocery Division Submit completed form to: <br /> Facility address: 16888 McKinley Ave SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10166883 ATTN: CAROL PRESTO <br /> 1868 E HAZELTON AVENUE <br /> PR0232523 STOCKTON, CA 95205 <br /> Violation##109-Failure to submit"Designated Underground Storage Tank Operator Identification Form" <br /> within 30 days. <br /> This violation was corrected ❑ This violation will be corrected by(date): <br /> Supporting documents included <br /> Des ribe actions taken or will be taken to qqrrect violation: <br /> Violation#115-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> This violation was corrected 11 This violation will be corrected by(date): <br /> ❑ Supporting documents included <br /> Describe actions t ken or will be taken to correct violati m Luv—\qu c—� ,i <br /> C-f)i AP <br /> Page 2 of 3 <br /> Rev.9/16f2020 <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 />