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s� t <br />AN )OA IN <br />Corrective Action Statement <br />p report HEALTH <br />RE: June 16, 2020, Hazardous Waste inspection re ort PER(1WjT�SERVICEU <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 form <br />with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please contact <br />Elianna Florido at (209) 468-0343 or eflorido@sjgov.org. <br />Facility name: <br />Facility address <br />'ERS ID: <br />SAFEWAY STORE 1769 <br />2808 COUNTRY CLUB BLVD <br />10414483 <br />PR0538350 <br />Submit completed form to: <br />SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />ATTN: ELIANNA FLORIDO <br />1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #108 -Failed to complete, sign or date manifest; or obtain dated signature of transporter. <br />This violation was corrected ❑ This violation will be corrected by (date): _ <br />❑ Supporting documents included <br />actions <br />taken or will be taken to correct violation:17 <br />h <br />Violation #110 -Failed to keep signed copy of manifests from the designated facility for three years. <br />This violation was corrected <br />d <br />❑ Supporting documents include <br />): <br />L <br />Describe actions taken or will be <br />❑ This violation will be corrected by (date <br />correct <br />Violation #111 -Failed to comply with uniform hazardous waste manifest exception requirements. <br />This violation was corrected <br />❑ E3 <br />Supporting documents included <br />Describe actions taken or will be taken to <br />This violation will be corrected by (date): <br />violation: <br />Page 2 of 2 <br />Rev. 8/27/2019 <br />1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 j F 209 464-0138 j www.sjcehd.com <br />