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Q lQ a Environmental Health Department <br /> CC)UN _... <br /> Corrective Action Statement <br /> RE: December 29, 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 Elianna Florido at(209)616-3050 or eflorido@sjgov.org. <br /> Facility name: ADELFO'S ARCO AMIPM Submit completed form to: <br /> Facility address: 3443 CHEROKEE RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10830655 ATTN. ELIANNA FLORIDO <br /> PRO542573 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 /> 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 /> Describe actions taken or will betaken to correct violation: <br /> 1 Vv1 L <br /> Page 2 of 4 <br /> Rev.9116/2020 <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 />