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SAN JDAWN Environmental Health Department <br /> C < � ( 11`111 Y <br /> Corrective Action Statement <br /> RE: July 19, 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: H&M - BW#98 Submit completed form to: <br /> Facility address: 2501 JACKSON AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181511 ATTN: KRISTINA SAETERN <br /> PR0231488 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation #104 - Failure to submits complete and accurate UST Monitoring Plan. <br /> Qj 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 /> WE- 020- J VoC V-41 2;41-1Ll�l do C.EZS <br /> Violation #118 -Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days. <br /> 15 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 /> fiW�LG +0 1btoi� 1Cyn`r7> LA01 �`r11acc,,� (\CSu1,k,, \o m-e Pn 1 e <br /> ii <br /> Violation #120 - Failure to submit and/or maintain documentation regarding compatibility for UST system <br /> components. <br /> ,0- 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 /> $�rn•GS C>�Y'�J �ulle r®ec�..;k6 • `t�:s iS �,r� d� z.t4l <br /> Page 2 of 3 <br /> Rev,911612020 <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 />