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5AN JUAUUIN <br />Environmental Health Department <br />Corrective Action Statement <br />RE: April 07, 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 dale. <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 Paul Nso at (209) 616-3049 or pnso@sjgov.org. <br />Facility name: GREWALS GAS & LIOUOR• <br />Facility address: 4,100 E FREMONT ST <br />'ERS ID: 10180875 <br />PR0231574 <br />Submit completed form to: <br />SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATFN: PAUL NSO <br />1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #102 -Failure to submit a complete and accurate application for a permit to operate a UST. <br />This violation was corrected ❑ Thls violation will be corrected by (date): <br />❑ Supporting documents included <br />:scrib actions taken or will be taken to correct violation: <br />Inti (ertn . AM Lt/ J z z 71 <br />h/ <br />Violation #110 -Failure to submit the "Underground Storage Tank Statement of Understanding and <br />Compliance Form". <br />This violation was corrected <br />❑ di <br />11 This <br />violation w111 be corrected by (date): <br />Supporting ocuments "Lo luded <br />Describe actions taken or will be taken to correct violation: <br />Page 2 of 3 <br />Rev. 9H812020 <br />1868 E, Hazelton Avenue i Stockton, CaOfomia 95205 j T 209 468-3420 (F 209 464-Q138 � www,sjgov,org/EHD <br />