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SAN JOAQUIN Environmental Health Corrective Action Statement RE , December 02 , 2019 , Underground Storage Tank inspection report For each violation listed below, indicate if the violation has been corrected or will be corrected by a certain date . FJso , describe what was done to correct the violation in the space provided below each violation . Submit this completed form with the Return to Compliance Certification within 30 days of Inspection . If you have any questions , please contact Shewit Woldeareqay at (209 ) 468-0216 or stwoldearegay (@slgov. orq . Facility name : ESCALON MINI MART Submit completed form to : Facility address : 1 .097 YOSEMITE AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT CERS ID: 10180561 ATTN : SHEWIT WOLDEAREGAY PR0231497 1868 E HAZELTON AVENUE STOCKTON , CA 95205 Violation #110 - Failed to submit " Secondary Containment Testing Report Form " within 30 days after the test. W/ This violation was corrected ❑ This violation will be corrected by (date) : ❑ Supporting documents Included Describe actions taken or will be taken to correct violation : L,.Ie /-%�i � � r �i1/ i %/' ri%// I 67j- l r 42 Violation #201 - Failure to maintain monitoring , maintenance, and follow up action records. This violation was corrected ❑ This violation will be corrected by ( date) : ❑ Supporting documents included Describe actions taken or will betakento correct violation : I Violation #209 Failure to conduct the designated UST operator visual inspection at least once every 30 days . R/ This violation was corrected ❑ This violation will be corrected by (date) : ❑ Supporting documents Included ' / Describe actions taken or will be taken to correct violation : ja /� /[�ilrl'lll o• a - 4 Imo4 lie Q Page 2. of 3 Rev. em019 1868 F . Hazellun Avenue I Stockton , California 95205 1 T 209 460 - 34201 F 209 464 - 0130 I w�«tiv . sics hd . rom