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� f1 � Environmental Health Department <br /> N{ V N <br /> -r <br /> -COUNTY <br /> Greatness grows here. <br /> Corrective Action Statement <br /> RE: September 18, 2025, 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 form <br /> with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please contact <br /> Monica De Anda at(209)616-3063 or mdeanda@sjgov.org. <br /> Facility name: SAFEWAY FUEL CENTER#0055 Submit completed form to: <br /> Facility address: 19533 S MOUNTAIN HOUSE PKWY SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10902574 ATTN: MONICA DE ANDA <br /> PR0547762 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#5-2030041 -A current facility plot plan is maintained and has been submitted. <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#8-2010016-"Underground Storage Tank Statement of Understanding and Compliance Form" <br /> submitted (TCR 10). <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#47-2030008-Secondary containment installed after July 1,2003 is free of water. <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 /> Page 2 of 3 <br /> Rev.9/16/2020 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />