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SAN 10 A Q U I N Environmental Health Department <br /> Corrective Action Statement <br /> RE : September 12 , 2022 , 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 Kristina Saetern at (209) 616-3045 or ksaetern@sjgov . org . <br /> Facility name : FOOD MART GASOLINE* Submit completed form to : <br /> Facility address : 2185 E FREMONT ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181081 ATTN : KRISTINA SAETERN <br /> PR0231118 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 /> .,0 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 /> 1,E (�1 L �.n L L c <br /> car c� e Lj-Dh-k k CAyr%�r rp Z C i, ,D k1A LH <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents . <br /> 3' 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 : i r <br /> � OLLf.LLk� hj <br /> Ig <br /> Violation #115 - Failure to submit " Monitoring System Certification Form" within 30 days of completion of the <br /> test. <br /> 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 : j — 1 1 L <br /> Gv C IFS Y� C't_ (I iegJ �; A h Y14 A� tjN , Y ( <br /> Y s� C\ t"rn F 1.1..N vv�_o. rl FJ1 <br /> Page 2 of 2 <br /> Rev, 9/16/2020 <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 />