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SAN J O A Q U I N Environmental Health Department <br /> Corrective Action Statement <br /> RE:July 19,2022,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. <br /> Also,describe what was done to correct the violation in the space provided below each violation. Submit this <br /> completed form with the Return to Compliance Certification within 30 days of inspection. If you have any questions, <br /> please contact Stacy Rivera at(209)616-3043 or srivera@sjgov.org. <br /> Facility name: BlackHawk Petroleum Inc. Submit completed form to: <br /> Facility address: 5611 E WATERLOO RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180881 ATTN:STACY RIVERA <br /> 1868 E HAZELTON AVENUE <br /> PR0231764 STOCKTON,CA 95205 <br /> Violation#107-Failure to submit and maintain complete and current financial responsibility documents. <br /> 0 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 /> ps c 41�w �rD-2 GCIc� <br /> N <br /> Violation#116-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> ff 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: pr' lv\vt\� 1�' G'C''C�Y a C-1 <br /> Violation#117-Failed to submit"Secondary Containment Testing Report Form"within 30 days after the test. <br /> This violation was corrected ❑This violation will be corrected by(date): <br /> ❑ Supporting documents included <br /> Describe actions taken or will betaken to <br /> t1 correct violation: <br /> 1-ti— <br /> Page 2 of 4 <br /> R.,e11612020 <br /> 1868E Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sjgov.org/EHD <br />