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SNAOUN Environmental Health Department <br />a COUNTY - <br />o. -al /* <br />UfE'i7fli�5`e y,`C"+1 !fttti <br />Corrective Action Statement <br />RE: May 06, 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. 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 Certification 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: Black Bear Diner Submit completed form to: <br />Facility address: 2351 Toste Rd SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />CERS ID: 10636675 ATTN: NICHOLAS LOEHRER <br />PR0540285 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 />CO/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 #6 - Failed to electronically submit a site map with all required content. <br />2 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 3 <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 />