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SAN r.J OAQ U I N Environmental Health Department c < � u r�l ry Corrective Action Statement RE : January 18 , 2023, Underground Storage Tank inspection report For each violation listed below, indicate if the violation has been corrected or will be corrected by a certain date. Also, describe what was done to correct the violation in the space provided below each violation. Submit this completed form with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please contact Kristina Saetern at (209) 616-3045 or ksaetern@sjgov.org. Facility name: KWIK SERV LODI BW 113* Submit completed form to: Facility address: 420 W KETTLEMAN LN SJC ENVIRONMENTAL HEALTH DEPARTMENT CERS ID: 10181407 ATTN : KRISTINA SAETERN PRO231906 1868 E HAZELTON AVENUE STOCKTON , CA 95205 Violation #115 - Failure to submit "Monitoring System Certification Form" within 30 days of completion of the test. ® This violation was corrected ❑ This violation will be corrected by (date): ❑ Supporting documents included Describe actions taken or will be taken to correct violation: ftl�l vj % % tea U;r.V yeC nfw Violation #116 , Failure to submit the "Spill Container Testing Report Form" within 30 days. ® This violation was corrected ❑ This violation will be corrected by (date): ❑ Supporting documents included '.. Describe actions taken or will be$taken to cgorrect violation: 'g 4, Violation #117 - Failed to submit "Secondary Containment Testing Report Form" within 30 days after the test. 13 This violation was corrected ❑ This violation will be corrected by (date): ❑ Supporting documents included Describe actions taken or will be taken to correct violation: C1ai LAN Page 2 of 3 Rev. 9/16/2020 1868 E. Hazelton Avenue i Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www. sjgov. org/EHD