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SAN 10AQUIN Environmental Health Department <br /> Corrective Action Statement <br /> RE: November 08, 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: Supervalu Submit completed form to: <br /> Facility address: 1990 N PICCOLI RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181455 ATTN:VICKY VANG-LEE <br /> PR0231820 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#107-Failure to submit and maintain complete and current financial responsibility documents. 7 <br /> A This violation was corrected 19 This violation will be corrected by(date): <br /> to Supporting documents included / A <br /> Describe actions taken or will be taken to correct violation: k7 <br /> eco°// <br /> � C7r7 J l/7'1d' 1 f bG Lf�W er! ■ II h /� c y,V C p r /�{�// I. �d <br /> Violation#109-Failure to submit"Designated Underground Storage Tank Operator Identification Form" <br /> within 30 days. l <br /> 10 This violation was corrected 19 This violation will be corrected by(date): <br /> 19 Supporting documents included ♦ /� <br /> Describe actions taken or will be taken to correct violation: a�7r�1 i�[!,I /I 1Q / L L� 'S <br /> `p'1^ f1 OIO� 11 mor ©V� �C�i61� 1� C/' 61i� <br /> Page 2 of 4 <br /> Rev.9116/2020 <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 />