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_ SAW <br /> -J aH I Environmental Health Department <br /> COUNTY <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 /> farm with the Return to Compliance Certification wfthin 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 /> PR0232523 1868 E HAZELTON AVENUE <br /> 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 r <br /> Describe actions taken or will be taken to j rect violation: <br /> w .. P_! n �� <br /> r ?� <br /> v- <br /> 122 <br /> Violation#115-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <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 vioiat' n: <br /> Page 2 of 3 <br /> Rev,911612020 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 1 www.sjgov.org/EHD <br />