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SAN <br /> JOAQUIN <br /> Environmental Health Department <br /> Corrective Action Statement <br /> RE : June 16 , 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 Elianna Florido at (209) 616-3050 or eflorido@sjgov.org . <br /> Facility name: MY MINI MART Submit completed form to : <br /> Facility address : 1756 N WILSON WAY SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10180819 ATTN : ELIANNA FLORIDO <br /> PR0231300 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #104 - Failure to have an approved UST Monitoring Plan . <br /> Itf This violation was corrected ❑ This violation will be corrected by (date) : <br /> ❑ Supporting documents included <br /> Describe actions oaken or will be taken to correct violation : <br /> Op J0 <br /> Violation #107 = Failure to submit and maintain complete and current financial responsibility documents . <br /> GI 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 /> Violation #115 - Failure to submit "Monitoring System Certification Form" within 30 days of completion of the <br /> test. <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 : <br /> Page 2 of 3 <br /> Rev. 9/16/2020 <br /> 1868 E . Hazelton Avenue i Stockton , California 95205 1 T 209 468- 3420 1 F 209 464- 0138 1 www . sjgov. org/EHD <br />