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S AN J O A Q U I N Environmental HeaIg g ent <br />t_, ll1' !TY <br />MAY 18 70?3 <br />Corrective Action Statement ENVIRONMENTAL <br />RE: February 07, 2023, Underground Storage Tank inspection repWALTH DEPARTMENT <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: SHOP N GO 3 <br />Submit completed form to: <br />Facility address: 4511 PACIFIC AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />'ERS ID: 10180943 ATTN: SHEWIT WOLDEAREGAY <br />PR0231216 1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #107 - Failure to submit and maintain complete and current financial responsibility documents. <br />. This violation was corrected <br />❑ Supporting documents included <br />❑ This violation will be corrected by (date): <br />Describe actions taken or will be taken to correct violation: <br />Violation #202 -Failure to retain a paper or electronic copy of the permit to operate at the facility. <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: <br />Violation #203 -Failure to maintain monitoring records for 36 months and maintenance records for 60 <br />months. <br />*Q( This violation was corrected [I This <br />Rev. 9/1612020 <br />violation will be corrected by (date): <br />❑ Supporting documents included a r / <br />Describe actions taken or will be taken to correct violation: ItId-e V) L (�' ( d <br />Page 2 of 3 <br />C1 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjgov.org/EHD <br />