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SAN JUAOUI N Environmental Health Department <br /> Y <br /> Corrective Action Statement <br /> RE: April 03, 2023, 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 Gabriela Garcia-Mejia at(209)616-3037 or ggarcia-mejia@sjgov.org. <br /> Facility name: PERSHING GAS FOR LESS Submit completed form to: <br /> Facility address: 4445 N PERSHING AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181565 ATTN: GABRIELA GARCIA-MEJIA <br /> PR0231785 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation 9116-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: y 1,,)1/1 MAgc— S U/lF TIG1`i m ON 1 1 0(LI►v(t <br /> x'151-6&1 CFQ11i 107iW o i IS 5Eu051h,;F� Ll/'/,Ij Iv Da, Ys al'- i/1cf- ;FC5;-,N <br /> Eu-7U <br /> Violation#116-Failure to submit the"Spill Container Testing 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: w 1 S VO-6 T%+7 A <br /> Co ���► 2 1'CSi,�C a -edtt 1 OLM 5'V1;071;i 6,b W11--WrN 50„DAYS ai= inF <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 taken to correct violation: S L-ILC MA k(= r✓rLF T/IJ SE'Cy•4D,9n— <br /> 1[Tr-4 � ilb2.i r4A 13 fUlia,,il'f--� WP9,.,i 30 DAYJ rWTK V16 r6c.L i•j <br /> r i ulte. <br /> Page 2 of 3 <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 />