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aQ { N Environmental Health Department <br /> Corrective Action Statement <br /> RE: January 25, 2021, Underground Storage Tank inspection report <br /> j For each violation listed below, indicate if the violation has been corrected or will be corrected by a certain date. <br /> j 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 /> i please contact Paul Nso at (209) 616-3049 or pnso@sjgov. org. <br /> Facility name: VAN DE POL ENTERPRISES INC Submit completed form to: <br /> Facility address : 816 E FRONTAGE RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10181513 ATTN: PAUL NSO <br /> PR0231470 1868 E HAZELTON AVENUE <br /> i STOCKTON , CA 95205 <br /> r <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents, <br /> fiV'This violation was corrected ❑ This violation will be corrected by (date ): <br /> 11111011 <br /> j ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: �. G�¢ S Y�Lts 1pn. AAqA <br /> cayle Qmtk th khe b�l�tpr. <br /> Violation #118 - Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days, <br /> Cd '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: _ 1► k nw, g wgpm Al Pee <br /> A.nu �in� Yhe� ► ak �ubr� �tlztt �. <br /> Violation #122 - Failure to implement corrections and submit written response within 30 days of receiving the <br /> report. <br /> GrThis violation was corrected ❑ This violation will be corrected by (date ): <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violationl j holic Wliec a. e j es-+�c nna-kt chat <br /> dU•n �� IVv 4 ,nu. . _ AA rr QO&S nunA C cis h bS ag, Ka ► % &UA <br /> olclytr dlcw ,, b .k . <br /> Page 2 of 4 <br /> Rev. 9/le/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 />