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SAN 10 A Q U I N Environmental Health Department <br /> L, T Y <br /> Corrective Action Statement <br /> RE : October 22 , 2019 , 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 . 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 /> Shewit Woldearegay at (209) 468-0216 or stwoldearegay@sjgov. org . <br /> LODI MEMORIAL HOSPITAL , 975 S FAIRMONT AVE , CERS ID : 10180611 , PR0231331 <br /> Violation #124 - " Overfill Prevention Equipment Inspection Report Form" not submitted within 30 days of <br /> inspection . <br /> Iff 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 : This was discussed with Afford a Test . <br /> This will not happen again . <br /> Violation #201 - Failure to maintain monitoring , maintenance , and follow up action records . <br /> ❑ This violation will be corrected b date <br /> This violation was corrected Y :( ) <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : This was discussed with Afford a Test . <br /> Document has been placed in inspection file <br /> Violation #204 - Current monitoring plan approved by the EHD not found on 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 /> Document has been placed in inspection file <br /> Page 3 of 4 <br /> Rev. 8/27/2019 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 F 209 464-0138 1 www . sjcehd . com <br />