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SAN J O A Q U I N Environmental Health Department <br />Corrective Action Statement <br />RE: July 19, 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 Stacy Rivera at (209) 616-3043 or srivera@sjgov_org. <br />Facility name: BlackHawk Petroleum Inc. Submit completed form to: <br />Facility address: 5611 E WATERLOO RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATTN: STACY RIVERA <br />CERS ID: 10180881 1868 E HAZELTON AVENUE <br />PR0231764 STOCKTON, CA 95205 <br />Violation #122 - Failure to implement corrections and submit written response within 30 days of receiving the <br />report. <br />❑ This violation was corrected his violation will be corrected by (date): `o <br />❑ Supporting documents included <br />n �tio —Ainnc 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 />❑ This violation was corrected ❑ This violation will be corrected by (date): <br />Q Supporting documents included <br />Describe actions taken or will be taken to correct violation: �' ��U I P <br />\C <br />Page 2 of 3 <br />Rev.9116/2020- <br />fi�3 f H=ii�'�ton Avenue. Slocklon C,ih(oii,: t»l_05 1 20t� 170 r}8 1 www slgov.orglEHD <br />