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S1If1 �AI Environmental Health Department <br /> -M1 - <br /> 11 V N <br /> C U N T <br /> r Greatness grows here, <br /> Corrective Action Statement <br /> RE: September 12, 2025, 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 /> Alberto Fernandez at(209)616-3037 or. <br /> Facility name: LODI MEMORIAL HOSPITAL Submit completed form to: <br /> Facility address: 975 S FAIRMONTAVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180611 ATTN:ALBERTO FERNANDEZ <br /> PR0231331 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Violation#2-2010010-Complete and accurate UST Operating Permit Application has been submitted.. <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#10-2030074-Annual Monitoring System Certification Form to the CUPA within 30 days of <br /> completion of the test. <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 />