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5 Environmental Health Department <br /> A JI <br /> � 'OU IT' • <br /> Corrective Action Statement <br /> RE: October 27, 2021, 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 Vicky Vang-Lee at(209)616-3028 or vvang-lee@sjgov.org. <br /> Facility name: KPMC MANAGEMENT INC, DBA:ARCO CHEROKEI Submit completed form to: <br /> Facility address: 900 S CHEROKEE LN SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180627 ATTN:VICKY YANG-LEE <br /> 1868 E HAZELTON AVENUE <br /> PR0231841 STOCKTON, CA 95205 <br /> Violation#115-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> ❑ This violation was corrected Vfihis violation will be corrected by(date): i <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: ! ® <br /> Violation#118-Failure to submit the"Overfill Prevention Equipment Inspection Report Form"within 30 days. <br /> ❑ This violation was corrected his violation will be corrected by(date): / 5 <br /> ❑ Supporting documents included 1 <br /> Describe actions taken or will be taken to correct violation: r0 fflai,4 4&1 <br /> walk in -315 <br /> Page 2 of 3 <br /> Rev.9/16/2020 1868 E. Hazelton Avenue i Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />