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SANc_� OAQUIN Environmental Health Department <br /> U <br /> ~ <br /> COUNTY - - . ' <br /> a�xl .;v <br /> ., " ` � rFotnc� ss c� rnr� s fere , <br /> Corrective Action Statement <br /> RE : July 27 , 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 . 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 Woldearegay at (209 ) 468-0216 or stwoldearegay apsigov. org . <br /> Facility name : H& M - BW #98 Submit completed form to : <br /> Facility address : 2501 JACKSON AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181511 ATTN : SHEWIT WOLDEAREGAY <br /> PR0231488 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #103 - Failure to submit and maintain complete and current financial responsibility documents . <br /> dThis violation was corrected ❑ This violation will be corrected by ( date) : <br /> t�/ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : �° ('� � Cli �n.c . Mir ckf\CC ICA <br /> �es ��� 1r� , 1{�i Inas b �a "Icy 4- b� b '► n � � r l � <br /> Violation #201 - Failure to maintain monitoring , maintenance, and follow up action records . <br /> Ef This violation was corrected ❑ This violation will be corrected by ( date) : <br /> [Er Supporting documents included <br /> Describe actions taken or will be taken to correct violation: 1 �,( , ; ` )t( _ +111 "1 M��,� VC} <br /> G �.c k L,i i '� • Yvl ,r--� , ( \l yG C'riSl -� �E Q�-Tt' SLY ►•E% c+ ' 1 Y�=`'S <br /> Violation #209 - Failure to conduct the designated UST operator visual inspection at least once every 30 <br /> days . <br /> 13' This violation was corrected ❑ This violation will be corrected by (date) : <br /> IV Supporting documents included <br /> Describe actions taken or will be taken to correct violation : <br /> l Cks I, i / � Iz� ICI E3ciyyl coo, <br /> �x�na� 1 <br /> Page 2 of 3 <br /> Rev. 8/27/2019 <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 I T 209 468-3420 1 F 209 464 -0138 1 www. sjcehd . com <br />