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SWAMI Environmental Health Department <br /> COUNTY <br /> Corrective Action Statement <br /> RE : October 14 , 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 Frederick Ernest at (209) 616-3026 or fernest@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 : FREDERICK ERNEST <br /> PR0232523 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #122 - Failure to implement corrections and submit written response within 30 days of receiving the <br /> report. <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: SSI will track inspection violations and send <br /> SJC EHD the supporting documents before the thirty day time limit. <br /> Page 2 of 2 <br /> Rev. 9/16/2020 <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 />