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Environmental Health Department <br />SAN.J0AOUIN <br />0 N T Y <br />Corrective Action Statement <br />RE: December 18, 2020, 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. 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 />Stacy Rivera at or srivera@sigov.org. <br />Facility name: ESCALON MINI MART Submit completed form to: <br />Facility address: 1097 YOSEMITE AVE SJC ENVIRONMENTAL HEALTH DEPARTMENT <br />CERS lo: 10180561 ATTN: STACY RIVERA <br />PR0231497 1868 E HAZELTON AVENUE <br />STOCICTON, CA 95205 <br />Violation #102 - Failure to submit a complete and accurate application for a permit to operate a UST. <br />® This violation was corrected This violation will be corrected by (date): i \ c ` . <br />® Supporting documents included <br />Desc ie actions taken or will be taken to correct violation:, <br />19Violation #107 - Failure to submit and maintain complete and current financial responsibility documents. <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 #109 - Failure to submit "Designated Underground Storage Tank operator Identification Form" <br />within 30 days. <br />® This violation was corrected ® This violation wili be corrected by (date): <br />❑ Supporting documents included <br />Describe actions taken or will be taken to correct violation:) % J a �) <br />Page 2 of 6 <br />Rev. 8127/2919 <br />1868 E. Hazelton Avenue j Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 I www.sjcehd.com <br />