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INSPECTION DATE : 07/ 13j2017 ___ ___. .___ _____--__ —� <br /> t COUNTY OF SAN DIEGO RECORD ID It : DEH2O02-HU_PFP^ 137226 <br /> r SPECIALIST : Daniel LaPel <br /> CORRECTIVE AC'T' ION FORM TO - - - <br /> INSPECTION CONTACT : Allegor Padernal <br /> ma=r DOCUMEN "I ' RETURN "1"0 COMPLIANCE TITLE : GasStation_ �_ - --�-- <br /> FACILITY NAME : Costco Wholesale €€460 PHONE : (619) 656-0826 <br /> ADDRESS: 895 E H ST F - MAIL : w460adtn@Costco .con1 <br /> CITY/ZIP : CHULA VISTA /91910 <br /> VIOL#€ DATE INDICATE HOW VIOLATIONS WERE CORRECTED DUE DATE <br /> CORRECTED ( Attach Any Supporting Documentation ) <br /> i <br /> t€ 1 2030008 07/13/ 2017 Corrected during inspection 08/ 12 / 2017 <br /> i <br /> €€ 2 2030013 08/ 12 /2017 <br /> i <br /> I certify under penalty of law flint this facility has corrected all violations marked on the Compliance Inspection neportMobce of LOolaooil. ! have prrs;mdiy e.raminerl cold am <br /> fomilior with the information submitted and believe the information is true, accurate and complete, I am authorized to fde this rertifrcnfron foo tho f l rbty, url (i rrm owarr! flint <br /> there are sirgnificont penalties for submitting false information , <br /> , PRINTED NAME OF FACILITY REPRESENTATIVE DA1F YGNED <br /> TITLE OF FACILITY REPRESENTATIVE j SIGNATURE <br /> SEND COMPLETED FORM AND SUPPORTING DOCUMENTATION TO THE ADDRESS LISTED BELOW <br /> COUNTY OF SAN DIEGO USE ONLY <br /> REVIEWED BY : DATE . <br /> SPECIALIST'S COMMENTS : <br /> E] All violations noted on date listed above were corrected <br /> i <br /> ❑ Based On Information Provided By The Facility ❑ RTC entered by Specialist on : <br /> ❑ Based On Field Verification By Specialist p RTC entered by Office Assistant on : <br /> I <br /> i <br /> Department of Environmental Health, Hazardous Materials Division , P .O. Box 129261 , San Diego , CA 92112- 9261 <br /> I http, : //www . sdrdeh . wj ? 858-505 -6880 <br /> I <br /> t <br /> 14W926(01/15) <br />