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S A N A AQ U I N Environmental Health Department <br /> COUNTY <br /> Corrective Action Statement <br /> RE: January 28,2022, 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 Elianna Florido at(209)616-3050 or efloddo@sjgov.org. <br /> Facility name: COUNTRY CLUB MOBIL CIRCLE K Submit completed form to: <br /> Facility address: 2575 COUNTRY CLUB BLVD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10118074 ATTN:ELIANNA FLORIDO <br /> PR0231070 1868 E HAZELTON AVENUE <br /> STOCKTON,CA 95205 <br /> Violation#101-Failure to obtain a permit to operate from the Elft including but not limited to unpaid permit <br /> fees. <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#102-Failure to submit a complete and accurate application for a permit to operate a UST. <br /> 9 This violation was corrected ❑This violation will be corrected b (date): <br /> :) <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: XC.9-9* -7 f-N Li <br /> Pr_,a <br /> Violation#107-Failure to submit and maintain complete and current financial responsibility documents. <br /> U/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: 17)L 14 1/a I-,..t C ca�c� Pooh <br /> C,h., ksloi+—r��r�� tnaC,) <br /> Page 2 of 6 <br /> Rnv,911WO20 <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s}gov.orglEHD <br /> � - I <br />