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SAN JOAQUIN Environmental Health Department <br /> Corrective Action Statement <br /> RE: December 27, 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 <br /> Facility name: ADELFO'S ARCO AM/PM Submit completed form to: <br /> Facility address: 3443 CHEROKEE RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10830655 ATTN: FREDERICK ERNEST <br /> PRO542573 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#122-Failure to submit-a Complete and accurate application for a Permit to operate a IdST. <br /> This violation was corrected 13 This violation will be corrected by(date): <br /> Supporting documents included <br /> Describe actions taken or will be taken to correct violation: 10L iA- aa(LLYN <br /> /T— <br /> Violation#115-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> $ This violation was corrected 0 This violation will be corrected by(date): <br /> 1, E3 Supporting documents included <br /> Describe actions taken or will be taken to correct violation: L�(3v A fill )(11U&P d <br /> Violation 4116-Failure to submit the"Spill Container Testing Report Form"within 30 days. <br /> This violation was corrected 11 This violation will be corrected by(date): <br /> i13 Supporting documents included <br /> Describe actions taken or will be taken to correct violation: 4 toIM A <br /> Rev.9/16/2020 Page 2 of 3 <br /> 1868 E.Hazelton Avenue I Stockton,California 952G5) T 299 468-342G I F 209 464-0138 1 Www.sjgov.orgjEHD <br />