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SAN J OAQ U I N Environmental Health Department <br /> C=_ ;7l_S N -1 Y <br /> ri <br /> _ ; err <br /> Corrective Action Statement <br /> RE : June 22 , 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 . 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 : MY MINI MART Submit completed form to : <br /> Facility address : 1756 N WILSON WAY SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10180819 ATTN : PAUL NSO <br /> PR0231300 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents . <br /> vVE] This violation was corrected ❑ This violation will be corrected by (date) : <br /> ❑ Supporting documents included <br /> Describe actions taken or will <br /> be taken to correct violation : <br /> iv.n. � c Sc �cLt, L A d �)C1x ). 00) e_il ea . <br /> Violation #117 - Failed to submit " Secondary Containment Testing Report Form" within 30 days after the test. <br /> This violation was corrected ❑ This violation will be corrected by (date) : <br /> ❑ Supporting documents included <br /> Describe) actions taken or will be take,�••ynAA to correct violation : II L <br /> In7lL� Kveim h ^ 0. T� ��- L� b � o v� --7L. YYLrd A 1'V�D�YLhe <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 />