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S A N J O A U I N Environmental Health Department <br /> c. . . . iA <br /> Corrective Action Statement <br /> RE: February 05, 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 /> Lynsey Sammons at (209) 616-3067 or Isammons@sjgov.org. <br /> SHOP N GO 3, 4511 PACIFIC AVE, CERS ID: 10180943, PR0231216 <br /> Violation #7 - 2010003 - Owner/Operator submitted DO form and/or informed the CUPA of any change(s) <br /> within 30 days (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 #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 #10 - 2030074 - Annual Monitoring System Certification Form to the CUPA within 30 days of <br /> completion of the test. <br /> FThis violation was corrected ❑ This violation will be corrected by (date): <br /> ❑ Supporting documents included <br /> Describe actions tak t or will be taken to correct violation: <br /> l T'Wj%k L w�- <br /> ,::2�) me It I <br /> Page 3 of 6 <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 />