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SAN J O A Q U I N Environmental Health Department <br /> (corrective Action Statement <br /> RE: July 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 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.: BlackHawk Petroleum Inc. Submit completed form to: <br /> Facility address: 5611 E WATERLOO RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180881 ATTN:VICKY VANG-LEE <br /> F° <br /> PR0231764 1868 E HAZELTON AVENUE <br /> STOCKTON,CA 95205 <br /> Violation#104-Failure to have an approved UST Monitoring Plan. <br /> -Z"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#107-Failure to submit and maintain complete and current financial responsibility documents. <br /> ❑This violation will be corrected by(date): <br /> Cr--This,violation was corrected) <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: <br /> �n < <br /> Violation#109-Failure to submit"Designated Underground Storage Tank Operator Identification Form" <br /> within 30 days. <br /> 1 ❑ <br /> This violation will be corrected by(date): <br /> This violation was corrected <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: <br /> Page 2of3 <br /> v.9/18/2020 <br /> lifornia 95205 T 209 468-34201 F 209 464-0138 1 www.slgoNl.org/EHD <br /> 1868 E. Hazelton Avenue I Stockton, Ca <br />