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SAN 10 A Q U ! N Environmental Health Department <br />Corrective Action Statement <br />RE: August 17, 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 Wang-lee@sjgov.org. <br />Facility name: Verizon Business: KINGCA Submit completed form to: <br />Facility address: 13850 N DE VRIES RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />CERS ID: 10181479 ATTN: VICKY VANG-LEE <br />PR0231547 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 El This violation will be corrected by (date): <br />❑ Supporting documents included <br />Describe actions taken or will be taken to correct violation: PiJr ✓'fes124 <br />of <br />Violation #122 - Failure to implement corrections and submit written response within 30 days of receiving the <br />report. <br />This violation was corrected <br />Supporting documents included <br />Describe actions taken or will be taken to correct violation: <br />❑ This violation will be corrected by (date): <br />Violation #208 - Failure to comply with the designated operator inspection requirements. <br />Rev. 9/16/2020 <br />This violation was corrected <br />❑ Supporting documents included <br />Describe actions taken or will be <br />❑ This violation will be corrected by (date): <br />to correct violation: <br />Page 2 of 2 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/EHD <br />