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05 / 04 / 2022 16 : 08 FAX 2094732214 DAVITA U0003 / 0010 <br /> SA <br /> . L� nvion �nental Health Department <br /> Corrective Action Statement <br /> RE : April 29 , 2022 , 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. <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 Robert Lopez at (209) 953 -6214 or rlopez@sjgov. org . <br /> Facility name: DELTA SIERRA DIALYSIS CENTER Submit completed form to : <br /> Facility address : 7500 WEST LN SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID : 10873174 ATTN: ROBERT LOPEZ <br /> PRO547248 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #5 - Failed to electronically submit hazardous materials inventory for all reportable materials on <br /> site . <br /> 9( This violation was corrected ❑ This violation will be corrected by (date ) : <br /> ,& Supporting documents included / f j <br /> Describe actions taken or will be taken to correct violation : Ci Cl � 'T t Ile) <br /> 04 <br /> f <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 /> ,d Supporting documents included /� <br /> De cribe actio s taken or will be taken to correct viol do C( ��7� .�'"AC� <br /> 0 t4 <br /> a . <br /> c F i'C re� Vc�44 uy <br /> Violation #10 - Failed to electronically update the HMBP within 30 days of substantial change in operations . <br /> l� This violation was corrected ElThis violation will be corrected by ( date) : <br /> J2' Supporting documents included 1 <br /> Describections taken or will be taken to correct vi Iation : <br /> Rev. 9/16!2020 <br /> Page 2 of 3 <br /> 1868 E . Hazelton Avenue i Stockton , California 952. 05 i T 209 468 - 3420 1 F 209 464 -0138 1 www . sjgov. org/EHD <br /> Received Time May , 4 ._ 2022 3 : 56PM No . 7188 <br />