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SAN J O A Q U I N Environmental Health Department <br /> COUNTY— <br /> ` r Greatness grows hero <br /> Corrective Action Statement <br /> RE: November 08, 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 Frederick Ernest at(209)616-3026 or fernest@sjgov.org. <br /> Facility name: COSTCO WHOLESALE#658 Submit completed form to: <br /> Facility address: 3250 W GRANT LINE RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10146285 ATTN: FREDERICK ERNEST <br /> PR0518288 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#111 -Failed to notify the EHD 48 hours prior to conducting testing. <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 /> 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: <br /> Violation#118-Failure to submit the"Overfill Prevention Equipment Inspection Report Form"within 30 days. <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 /> Page 2 of 7 <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 />