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SWrJOAN NEnvironmental Health Department <br />Cr0kiNVY <br />Corrective Action Statement <br />RE: January 18, 2022, Underground Storage Tank inspection report <br />For each vlolatlon listed below, indicate if the violation has been corrected or will be corrected by a certain date. Also, <br />describe what was done to correct the violation in the space provided below each violation. Submit this completed <br />form with the Return to Compliance Certification within 30 days of Inspection. If you have any questions, please <br />contact Paul Nso at (209) 616-3049 or pnso@sjgov.org. <br />Facility name: <br />Facility address: <br />CERS ID: <br />KWIK SERV LODI BW 113" <br />420 W KETTLEMAN LN <br />10181407 <br />PR0231906 <br />Submit completed form to: <br />SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATTN: PAUL NSO <br />1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #'117 -Failed to submit "Secondary Containment Testing Report Form" within 30 days after the test. <br />'® Thls vloiation was corrected <br />❑ Supporting documents included <br />❑ This vlolatlon will be corrected by (date): <br />Describe actions taken or wi(I be taken to correct violation: <br />Violation #208 -Failure to comply with the designated operator inspection requirements. <br />ffil. This violation was corrected <br />❑ Supporting documents included <br />❑ This violation will be corrected by (data): <br />Describe actions taken or will be taken to correct vlolatlon: <br />Page 2 of 2 <br />Rev. 91f 612020 <br />1868 E. Hazelton Avenue i Stockton, California 95205 (T 209 468-3420 i F 209 464-0138 i www.s]gov.orglEHD <br />Tv\ <br />►Z <br />