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SKJOAQUIN Environmental Health Department <br />.� . <br />—COU NTY- <br />Greatness grows here. <br />Corrective Action Statement <br />RE: January 25, 2021, 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) 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 />STOCKTON, CA 95205 <br />Violation #107 - Failure to submit and maintain complete and current financial responsibility documents. <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 #118 - Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days <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 #122 - Failure to implement corrections and submit written response within 30 days of receiving the <br />report. <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 4 <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 />