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S A N J a A 4 u I N Environmental Health Department <br /> ^. -y <br /> Corrective Action Statement <br /> RE: June 06, 2023, Underground Storage Tank inspection report <br /> Far each violation listed below,indicate if the violation has been corrected or wiif 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 Stacy Rivera at(209)616-3043 or srlvera@sjgov.org. <br /> Facility name: RANCHO SAN MIGUEL MARKET' Submit completed form to: <br /> Facility address: 1427 S AIRPORT WAY SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS 1D: 10184829 ATTN:STACY RIVERA <br /> PRO521942 1868 E HAZELTON AVENUE <br /> STOCKTON,CA 95205 <br /> Violation#107-Failure to submit and maintain complete and current financial responsibility documents. <br /> id This violation was corrected ❑This violation will be corrected by(date): <br /> R' Supporting documents included <br /> Describe actions taken or will be taken to correct violation: financial Responsibility has been updated on <br /> CERS. a Copy will be sent with the corrective action statement. a COPY will be onsite for review. <br /> Violation#113-Failure to conduct secondary containment 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: Service Station has been notified for the Correct <br /> dates for secondary Inspection. moving forward .Jesus Jurado will ensure all testing are scheduled before <br /> the due dates. <br /> Violation#117-Failed to submit"Secondary Containment Testing Report Form"within 30 days after the test. <br /> IV This violation was corrected 0 This violation will be corrected by(date): <br /> Supporting documents included <br /> Describe actions taken or will be taken to correct violation: A Copy of secondary containment testing amended <br /> report for 11/24/2022 alon with the piping certification for the technician performing the test will be <br /> sent with the corrective action statement. <br /> Rai.911612020 <br /> Page 2 of 3 <br /> 1868 E.Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />