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SAN J0AQUIN Environmental Health Department <br /> Q <br /> C O U N T Y <br /> Greotness grows here. <br /> Corrective Action Statement <br /> RE: September 27, 2023, 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 Shewit Woldearegay at(209)616-3063 or stwoldearegay@sjgov.org. <br /> Facility name: SAFEWAY FUEL CENTER#0055 Submit completed form to: <br /> Facility address: 19533 S MOUNTAIN HOUSE PKWY SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10902574 ATTN:SHEWIT WOLDEAREGAY <br /> PR0547762 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#115-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> M 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: The testing was performed by the Installing <br /> contractor, not our regular testing company. Our regular testing company knows the <br /> 30 day submittal requirement and has a track record of submitting results on time. <br /> Violation#116-Failure to submit the"Spill Container Testing Report Form"within 30 days. <br /> N 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 /> The testing was performed by the installing <br /> contractor, not our regular testing company. Our regular testing company knows the <br /> 30 day submittal requirement and has a track record of submitting results on time. <br /> Violation#118-Failure to submit the"Overfill Prevention Equipment Inspection Report Form"within 30 days. <br /> M This violation was corrected ❑This violation will be corrected by(date): <br /> ❑ Supporting documents included <br /> The testing was performed by the installing <br /> Describe actions taken or will be taken to correct violation: <br /> contractor, not our regular testing company. Our regular testing company knows the <br /> 30 day submittal requirement and has a track record of submitting results on time. <br /> Page 2 of 4 <br /> Rev.9/16/2020 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/EHD <br />