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SAN 10 A Q U I N Environmental Health Department <br /> OtiN FY <br /> Grratnoss grov.,5 ! <br /> Corrective Action Statement <br /> RE: September 27, 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 Lydia Baker at(209)616-3046 or lbaker@sjgov.org. <br /> Facility name: ST JOSEPHS HOSPITAL Submit completed form to: <br /> Facility address: 1800 N CALIFORNIA ST SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10181391 ATTN: LYDIA BAKER <br /> PR0231036 1868 E HAZELTON AVENUE <br /> STOCKTON. CA 95205 <br /> Violation#107-Failure to submit and maintain complete and current financial responsibility documents. <br /> 10/his violation was corrected El This violation will be corrected by(date): <br /> tF Supporting documents included <br /> Describe actions taken or will be taken to correct violation: T f/,Iry/1f C.a1 A L- y��SpCS� fl <br /> 5-16 <br /> Violation#109-Failure to submit"Designated Underground Storage Tank Operator Identification Form" <br /> within 30 days. <br /> VelThis violation was corrected ❑This violation will be corrected by(date): <br /> "upporting documents included � icy <br /> w <br /> Describe actions taken or will be taken to correct violation: d Ulf !� � l �zrrr-0 1�� fidg-m <br /> 96C fIbRA T-Ori-IS ACZ0 <br /> ConIOUA -6- Ptl APPEODU <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 />