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5A +tQAQUI Environmental Health Department <br /> CC)UNTY <br /> hIell- <br /> Corrective Action Statement <br /> RE: September 27, 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 <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)468-3432 or pnso@sjgov.org. <br /> Facility name: WEST LANE CHEVRON Submit completed form to: <br /> Facility address: 4747 WEST LN SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181343 ATTN: PAUL NSO <br /> 1868 E HAZELTON AVENUE <br /> PR0232482 STOCKTON, CA 95205 <br /> Violation #118 - Failure to submit the "Underground Storage Tank Statement of Understanding and <br /> Compliance Form". <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 c rrect violation: <br /> Q <br /> -is, 9,,e4i <br /> i12 00/Z <br /> L D <br /> r <br /> Violation#209 - Failure to conduct the designated UST operator visual inspection at least once every 30 <br /> days. <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: i <br /> Page 2 of 2 <br /> Rev.812712019 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />