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SAN 10AWN <br /> 91 <br /> Health Department <br /> Corrective Action Statement <br /> RE : May 31 , 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 Kristina Saetern at (209) 616-3045 or ksaetern@sjgov .org . <br /> Facility name: PARKWOODS GAS & FOOD Submit completed form to: <br /> Facility address : 1612 W HAMMER LN SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181241 ATTN : KRISTINA SAETERN <br /> 1868 E HAZELTON AVENUE <br /> PR0231127 STOCKTON , CA 95205 <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents . <br /> This violation was corrected 13This violation will be corrected by (date) : 13 <br /> ❑ Supporting documents included I <br /> Describe actions taken or will be taken to correct violation : r/� w <br /> V we � -5'„ w. � 1* o CerS <br /> Violation #116 • Failure to submit " Monitoring System Certification Form" within 30 days of completion of the <br /> test. <br /> B"/ <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 /> V\ e, J - 1 � w , SJ bM taOL {-v l ✓� 3U o( <br /> Violation #208 - Failure to comply with the designated operator inspection requirements . <br /> 91aaaaaa <br /> This violation was corrected ❑ This violation will be corrected by (date) : <br /> ( • f3 . 23 <br /> ❑ Supporting documents included <br /> -�- w . I ( wl � � s� r-e- <br /> Describe actions taken or will be taken to correct violation : A <br /> C �v" MAL C) �..� W%A <br /> Page 2 of 2 <br /> fay. 91IW2020 <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468- 3420 1 F 209 464-0138 1 wvvrw . sjgov . org/EHD <br />