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SAN ; DAWN Environmental Health Department c < � trrl I v Corrective Action Statement RE : July 19 , 2023 , Underground Storage Tank inspection report For each violation listed below, indicate if the violation has been corrected or will be corrected by a certain date. Also, describe what was done to correct the violation in the space provided below each violation. Submit this completed form with the Return to Compliance Certification within 30 days of inspection . If you have any questions, please contact Kristina Saetern at (209) 616-3045 or ksaetern@sjgov.org. Facility name: H&M - BW #98 Submit completed form to: Facility address: 2501 JACKSON AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT CERS ID: 10181511 ATTN: KRISTINA SAETERN PR0231488 1868 E HAZELTON AVENUE STOCKTON, CA 95205 Violation #104 - Failure to submits complete and accurate UST Monitoring Plan. Qj This violation was corrected ❑ This violation will be corrected by (date): ❑ Supporting documents included Describe actions taken or will be taken to correct violation: I 04�� AVE WE " ® rjlo — J For R C� SaL`�4 On GEi25 Violation #118 - Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days. 15 This violation was corrected ❑ This violation will be corrected by (date): ❑ Supporting documents included Describe actions taken or will be taken to correct violation : f2!W6 LG 4-o 1Q' Q_p n` Li e4+.P� A`4.1e,,,\ �G u �k c, 10-e taJ �n�i\ ?6 cid.sl� C.n (�C.� � Q.�1 ! �✓� `� � Nnlx Violation #120 , Failure to submit and/or maintain documentation regarding compatibility for UST system components. jk}- This violation was corrected ❑ This violation will be corrected by (date): ❑ Supporting documents included Describe actions taken or will be taken to correct violation: $ ojrn•GS 0440 dull C ®eco. k6 • tom: s iS r� d � 2 t41 Page 2 of 3 Rev, 911612020 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov. org/EHD