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• - Ide 'A�—Ilk <br /> # ^ �,� SNN �J OAQUIN Environmental Health Department <br /> . couryT <br /> IL Grcotness groves here ., <br /> Corrective Action Statement <br /> RE : August 25 , 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 . <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 Gabriela Garcia-Meiia at (209) 616-3037 or ggarcia-mejia@sjgov . org . <br /> Facility name : EI Dorado Food Mart Submit completed form to -, <br /> Facility address -. 1901 S ELDORADO STSJ ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10180839 ATTN : GABRIELA GARCIA- MEJIA <br /> PR0231092 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #116 - Failure to submit " Monitoring System Certification Form" within 30 days of complQtion of the <br /> test <br /> This violation was corrected El This violation will be corrected by ( date) : <br /> O Supporting documents included <br /> Describe actions taken or will bet en to correct violation : <br /> % 1111111111111111111 11,11,11111111 <br /> 111111111111 11,11,11111111 pporppmpq <br /> 001 j r;;t 40OWMIkd I AW00 V11 <br /> 0 "A --0) <br /> r7 <br /> Violation # 1 16 - Failuro 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 /> D Supporting documents includod <br /> Describe actions taken or will be ken to correct viola ion : <br /> k JUL <br /> I C>\ Re <br /> do I I <br /> Violation #117 - Failed to submit "Secondary Containment Testing Report Form " within 30 days after the test. <br /> ❑ This violation was corroctod D This violation will bo corrected by (date) : <br /> ❑ Supporting documents included <br /> Describe actions taken or will be tak n to correct violation : <br /> 00 <br /> oel 4M <br /> M111111111111 iiiilllliiiiiiiillllllljiiiillllm. <br /> jr <br /> Page 2 0( 4 <br /> Rev 0/ IF✓?010 <br /> 1868 E Hazelf on Avenue S locklon, California 95205 1 T 20 9 4 Gf3 ;1420 F 209 4 G4 013 8 www c-,j' g ov org/E H D <br />