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SAN JOAHIN <br />Environmental health Department <br />COrreLive Acti®n 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 inspcction. If you have any questions, please contact <br />Stacy Rivera at or srivera@sigov.org. <br />ESCALON MINI MART, 1097 YOSEMITE AVE, CERS ID: 10180561, PR0231497 <br />Violation #115 - Failure to submit "Monitoring System Certification Form" within 30 days of completion of the <br />test. <br />lq �02/ <br />❑ This violation was correctedThis violation will be corrected by (date): <br />® Supporting documents included -4. <br />Describe actions taken or will be taken to correct violation: 1 �. � <br />Violation #116 - Failure to submit the "Spill Container Testing Report Form" within 30 days. <br />❑ This violation was corrected This violation will be corrected by (date): c <br />® Supporting documents included <br />Describe actions taken or will be taken to correct violation: � � L <br />I7 rr <br />Violation #118 - Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 <br />days. <br />v/� <br />❑ This violation was corrected <br />❑ Supporting documents included <br />Describe actions taken or will be taken <br />El This violation will be correctod by (date): <br />correct violation: <br />Page 3 of 6 <br />Rev. 8/2712019 <br />1868 E. HazeWop Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />