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05/12/2021 12:16 FAX la0003/0008 <br /> SAN ,OAQ U I N Environmental Health) Department <br /> Corrective Action Statement <br /> RE: May 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. 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 Ceitification within 30 days of inspection. If you have any questions,please contact <br /> Nicholas Loehrer at(209)468-0623 or nloehrer@sjgov.org. <br /> Facility name: Manteca Dialysis Submit completed form to: <br /> Facility address: 1620 W Yosemite Ave SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10733509 ATTN: NICHOLAS LOEHRER <br /> PRO543667 1868 E HAZELTON AVENUE <br /> STOCKTON,CA 95205 <br /> Violation#4-Failed to electronically submit the Business Activities or Owner/Operator Identification page. <br /> This violation was corrected ❑This violation will be corrected by(date): SI 1Z 12.I <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: N,)5ln?13 Mhybt) Oy Own e r- <br /> o t2Lh(- i cls n i c(Atn WW WCA) n)bm I�' O 1-0 (ac-) _I_,-___— <br /> C\(K\A' Q\ UUY)UrC a UrfifiCXRho)o r��_ Sh,2 z , AnnvaI <br /> 5vhm55\0n OG kh�-'-p E7aa uA1 lh'e don-e h( )an 1%or each <br /> Ccnllend0T -t-CGr US (A (3110y) of c<Drrc c 10n <br /> Violation#5-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): S I fZ I ZI <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation: WA-) yCbJ) WAV n Ups iny,2610'! <br /> Ry _L11 1Z�Acy))e mrl vic�IS on s,+.P- WcA) <br /> 4-11 C-ja%-AfCa <(Cr IA5Qvt, n, ud'iFi'tat1 c)n 5h2j21 Annual S'Uhrnis`ICn <br /> oy kmw- F&m will hf ctone )cAn islay each callm.d n - <br /> ` -eCa'r GJ 0\ (JI CAO d� C0TVT Cts bn <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 C <br /> Describe actions taken or will be taken to correct violation: }lit MCAD Wilih CA�� tICIA IM 6 <br /> C P&-A" c( hon On Sl 12,12-1 , AboU21 s 119M(S sl y) Or 411f)-e Forms <br /> t ) n c (IP dar <br /> ow 0�'- commcd) <br /> Page 2 of 4 <br /> Rev.9116/2020 <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 />