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SAN 10 A Q U I N Environmental Health Department <br /> -- -COUNTY <br /> r <br /> Corrective Action Statement: <br /> RE: July 07, 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. <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 Vicky Vang-Lee at(209)616-3028 or vvang-lee!@sjgov.org. <br /> Facility name: BlackHawk Petroleum Inc. Submit complleted form to: <br /> Facility address: 5611 E WATERLOO RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180881 ATTN:VICKI'VANG-LEE <br /> PRO520119 1868 E HAZELTON AVENUE <br /> STOCKTON,CA 95205 <br /> Violation#4 -Failed to electronically submit the Business Activities or Owner/Operator Identification page. <br /> '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 /> \� q C ec�� <br /> Violation#6 .-Failed to electronically submit hazardous materials inventory for all reportable materials on <br /> site. _� <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 /> C e1 <br /> Violation #6 - Failed to electronically submit a site map with all required content. <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 /> 3 <br /> Page 2of4 <br /> w. �eno2o <br /> -0138 www.sjgov.orglEHD <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 F 209 464 <br />