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M�I� Environmental Health Department <br />u <br />'--COUNTY— <br />Greatness <br />COUNT <br />Greatness grows here, <br />Corrective Action Statement <br />RE: May 03, 2021, Hazardous Materials 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 form <br />with the Return to Compliance Certification within 30 days of inspection. If you have any questions, please contact <br />Nicholas Loehrer at (209) 468-0623 or nloehrer@sjgov.org. <br />Facility name: MANTECA WELL #28 Submit completed form to: <br />Facility address: 802 SLALOM DR SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />CERS ID: none ATTN: NICHOLAS LOEHRER <br />PR0546871 1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Violation #2 - Failed to initially complete and electronically submit a HMBP. <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: <br />Violation #3 - Failed to establish and implement a hazardous materials business plan. <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: <br />Violation #4 - Failed to electronically submit the Business Activities or Owner/Operator Identification page. <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: <br />Page 2 of 5 <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 />