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SAN JOAQUIN <br /> Environmental Health Department <br />- --COUNTY <br />Greotnesi vows <br />Corrective Action Statement <br />RE: November 19, 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 <br />form with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please <br />contact Paul Nso at (209) 616-3049 or pnso@sjgov.org. <br />Facility name: Supervalu <br />Facility address: 1990 N PICCOLI RD <br />CERS ID: 10181455 <br />PRO231820 <br />Submit completed form to: <br />SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATTN: PAUL NSO <br />1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #104 - Failure to have an approved UST Monitoring Plan. <br />EVI This violation was corrected la This violation will be corrected by (date): //— 1°1 <br />Supporting documents included <br />Describe actions taken or will be taken to correct violation: dr-)Tr,,, //IA) CtL171 7,44,y • <br />jec I ,A.4n-i,7-7,41 ityp, 4rt I r <br />/ <br />Violation #107 - Failure to submit and maintain complete and current financial responsibility documents. <br />This violation was corrected 13/This violation will be corrected by (date): <br />Supporting documents included <br />Describe actions taken or will be taken to correct violation: <br />C 74 7/ '1-,d2( <br />///) //-/G7--).02t, <br /> <br />eV'fif apid <br /> <br />Violation #109 - Failure to submit "Designated Underground Storage Tank Operator Identification Form" <br />within 30 days. <br />This violation was corrected 1E1 This violation will be corrected by (date): //—/q-2 027 <br />Supporting documents included <br />Describe actions taken or will be taken to correct violation: Z1 6-67U de( ofc <br />Page 2 of 5 <br />Rev. 9/16/2020 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/EHD