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SAN �JOAQ JIN Environmental Health Department <br /> --COUNT" <br /> ---- <br /> Greatness grows hFr-' <br /> Corrective Action Statement <br /> RE: May 12, 2020, 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 Paul Nso at(209)468-3432 or pnso@sjgov.org. <br /> Facility name: SAFEWAY FUEL CENTER#2707 Submit completed form to: <br /> Facility address: 6425 N PACIFIC AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10156811 ATTN: PAUL NSO <br /> PR0231211 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#110 -Failed to submit"Secondary Containment Testing Report Form"within 30 days after the test. <br /> ® This violation was corrected D This violation will be corrected by(date): <br /> 12 Supporting documents included <br /> SB989 testing documentation was submitted <br /> Describe actions taken or will be taken to correct violation: <br /> to EHD on 6/10/2020. Attached to email as well. <br /> Violation#113 -Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> ® This violation was corrected D This violation will be corrected by (date): <br /> 0 Supporting documents included <br /> Describe actions taken or will be taken to correct violation: 5/14/2019 Monitor Cert attached to email. <br /> Page 2 of 3 <br /> Rev.8/27/2019 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />