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SAN JOAQUIN Environmental Health Dopartment <br /> Corrective Action Statement <br /> RE : June 05 , 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 . 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 Paul Nso at (209) 616-3049 or pnso@sjgov. org . <br /> Facility name: TIWANA GAS & FOOD Submit completed form to: <br /> Facility address: 1210E HAMMER LN SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181355 ATTN : PAUL NSO <br /> PR0231125 1868 E HAZELTON AVENUE <br /> ® STOCKTON , CA 95205 <br /> Violation #102 - Failure to submit a complete andel accurate application for a permit to operate a UST. <br /> ❑ This violation was corrected t( This violation will be corrected by (date): <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : Tv) e ree� S'"^ <br /> iSnod ha ✓ c o� � C �Sa 6w PICLCt Uri <br /> Lan 'A rte' aIk r 1� r � S � � h � � rw ,.. Us <br /> ' WIL k( ov Id kt*L,r(. -}o a✓'t A Cam a lr 4.v` �t� � 5 � � us <br /> � ��, •dd / w /L �/N.� Q. } �" ® ✓ h6 } es twJo/` <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents . <br /> This violation was corrected ❑ This violation will be corrected by (date): 6 ( 3 " L ? <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : <br /> GSL <br /> VVI 14 hew � hwt etL -e Se' onS � � , J , o Carl ( ex S- - - <br /> Violation #117 - Failed to submit "Secondary Containment Testing Report Form" within 30 days atter the test. <br /> 0 This violation was corrected ❑ This violation will be corrected by (date): 13 ` L, <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : 3� w; It me% t�k LU <br /> -�►... 3 vt s o f 1�n �o � 1(04%00� -,f <br /> Page 2 of 3 <br /> Rev. 9!16/2020 <br /> 1868 E . Hazelton Avenue ( Stockton , California 952051 T 209 468- 3420 1 F 209 464 - 0138 1 www , sjgov . org/ EHD <br />