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Corrective Action Statement <br /> RE: September 20, 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: FOOD MART GASOLINE* Submit completed form to: <br /> Facility address: 2185 E FREMONT ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181081 ATTN: KRISTINA SAETERN <br /> PR0231118 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#115-Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> Iff 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: 1 <br /> C', C�Cti /—usk +C ry u� <br /> f11�ti�_�A 'N <br /> Violation#116-Failure to submit the"Spill Container Testing Report Form"within 30 days. <br /> k,O 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 /> 2�►ti I� A� kc-ro c` T. _, 47� C4 AlMvr YV <br /> 'rA YVL(� IA n D-rNY-,9)L <br /> Page 2 of 3 <br /> Rev.9/16/2020 <br />