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5.")AN JOAQUIN <br /> Environmental Health Department <br /> . N T-Y <br /> Corrective Action Statement <br /> RE: June 06, 2022, Underground Storage Tank inspection report <br /> For ea,-h violation listed below, indicate if the violation has been corrected or will be corrected by a certain date. <br /> Also,c escribe 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 /> Facilit name: HARNEY LANE AM PM Submit completed form to: <br /> Facilib address: 255 E Harney Ln SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10484500 ATTN:VICKY YANG-LEE <br /> PR0537549 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 /> IE 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: 60 C-e-V1/11( d2 ' 'L' <br /> o <br /> S �'or 7 >�—, d �r es'e l ate, a.,o) <br /> c/ <br /> Violation <br /> �`� o� G� ►�S <br /> Viola ion#122-Failure to implement corrections and submit written response within 30 days of receiving the <br /> report. <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: _ <br /> O rY`2 fil��G"j f O�►d W r- h 2 .5;'O'"7_V e J' a,r� S'CJV h-i.�14"of <br /> Page 2of2 <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 />