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S A N J O A Q U I N Environmental Health Department <br /> C :Vit _: I\I T Y <br /> Corrective Action Statement <br /> RE : July 02 , 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@sjgov. org , <br /> Facility name: QUIK STOP MARKET #2076'` Submit completed form to : <br /> Facility address : 1030 S OLIVE ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10180695 ATTN : SHEWIT WOLDEAREGAY <br /> PR0231704 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #103 - Failure to submit and maintain complete and current financial responsibility documents . <br /> IQ 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 /> Financial responsibility documents have been included in the new compliance binders that will be onsite <br /> next week. <br /> Violation #113 - Failure to submit " Monitoring System Certification Form" within 30 days of completion of the <br /> test. <br /> 6 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 /> Future reports will be submitted within the required time frame , <br /> Violation # 123 - Failure to submit the "Spill Container Testing Report Form" within 30 days after the test. <br /> IN 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 /> Future reports will be submitted within the required time frame . <br /> Page 2 of 3 <br /> Rev. 8/27/2019 <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www. sjcehd . com <br />