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SAN JOAQUIN Environmental Health Department <br /> - COUNT1 <br /> Corrective Action Statement <br /> RE : February 07 , 2020 , 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 Paul Nso at (209 ) 468-3432 or pnso@sjgov . org . <br /> Facility name : DAMERON HOSPITAL Submit completed form to: <br /> Facility address : 525 W ACACIA ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181003 ATTN: PAUL NSO <br /> PR0231002 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #103 - Failure to submit and maintain complete and current financial responsibility documents . <br /> Z 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 /> a�� cb% CCljj i \ rtinko r ek <br /> Violation #118 - Failure to submit the " Underground Storage Tank Statement of Understanding and <br /> Compliance Form " . <br /> ❑ This violation was corrected ❑ This violation will be corrected by (date ) : <br /> )R — Supporting documents included <br /> Describe actions taken or will be taken to correct violation : <br /> Rev. 8/27/2019 Page 2 of 3 <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www . sjcehd . com <br />