Laserfiche WebLink
SAN 10A Q U I N Environmental Health Department <br /> Corrective Action Statement <br /> RE : December 17 , 2019 , 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. 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 /> Shewit Woldearepay at (209 ) 468-0216 or stwoldearenavraasigov.org , <br /> Facility name: CITY GAS & LIQUOR Submit completed form to: <br /> Facility address : 16470 CAMBRIDGE ST SJC ENVIRONMENTAL HEALI H DEPARTMENT <br /> CERS ID : 10779784 ATTN : SHEWIT WOLDEAREGAY <br /> PR0231532 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #113 - Failure to submit "Monitoring System Certification Form" within 30 days of completion of the <br /> test. <br /> This violation was corrected ❑ This violation will be corrected by (date) : <br /> El Supporting documents included 4 <br /> 1 <br /> Describe actions taken or will be taken to correct violation: (��li 49OFF <br /> � t. <br /> Violation #124 - "Overfill Prevention Equipment Inspection Report Form" not submitted within 30 days of <br /> Inspection. <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 4 <br /> Rev. WV2018 <br /> 1868 E . Hazelton Avenue I Stockton , California 952051 T 209 468-3420 i F 209 464.0138 1 www.sicohd . com <br />