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SAN J O AQ U I N Environmental Health Department <br /> Corrective Action Statement <br /> RE: March 08, 2024, 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 Matthew Won at(209)616-3029 or MWON@SJGOV.ORG. <br /> Facility name: MAIN STREET ARCO AM PM' Submit completed form to: <br /> Facility address: 1100 S MAIN ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10182243 ATTN: MATTHEW WON <br /> 1868 E HAZELTON AVENUE <br /> PR0506504 STOCKTON, CA 95205 <br /> Violation#106-Failure to submit and maintain a current facility plot plan 1 site map. <br /> 9 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: Me C,0p KF,,,4T PLOT PLPM <br /> Wpb uPLCk+�`O eN c.00.S (AT'nUc F-D) kf:TIrp- PNAk4,kMG ( EvIS\C)-A Qt4 <br /> 3 'Z2- L E - "t <br /> Violation#109-Failure to submit"Designated Underground Storage Tank Operator Identification Form" <br /> 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: M15SltA& INFO CYN 'The 9ESlt�NhTt.D <br /> 1;i SToR�Gt TA-NV.. &F-OTO- OeMTIi-%CAV214 halm WAS MbbED A-tjj_IT'_ wMs <br /> 2-4 CX9,L-C-Ta 41ESj Co PA AVA-IL- 5L-6 ON 51ri <br /> N L <br /> Violation#117-Failed to submit"Secondary Containment Testing Report Form"within 30 days after the test. <br /> AThis 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: 'TI.11= 5�2 C-0Q 6kLA tF--SIi WA <br /> REpbR,f FoL1'V\ WRS DiILtLTL`I SE"Z try I S-CItJG TtCA4 C..CN\P"f AFTER <br /> 3c Oh ,4 "E -TC SCCAE Ctmyus►et�1 /rN� Ov�N�KSH\P C.h W&G, OF -TWE -fEStt i <br /> op- CoOkhtTING Ce)MPWj MAAeNT IAI b <br /> Page 2 of 2 <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 />