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I na Fuel Storage and Piping lnspectioi rmj <br /> State Water Resources Control Board, Clean Watei :rog'rams <br /> - -1pp,Jrl <br /> Facility Information <br /> Facility Name <br /> L�w C, i_�, V "2 <br /> Facility Physical Address <br /> County_S �V\ �J` A Facility Telephone <br /> Facility Owner 1� P ( Lv y1 Y I�- e—A— <br /> t S11 $��_ 1� 9 <br /> Owner Mailing Address 3 <br /> Owner Telephone <br /> Facility I.D.# l ! ✓ Y.Rrivate Ownership ❑ Gov't Ownership <br /> Inspector Information <br /> Agency Conducting Inspection �a� �L�'r 4 Jy I CCLt ] <br /> ` Phone Numbed' f <br /> Inspector's Name 6x 1 <br /> Date of Inspection- <br /> General Site Information <br /> Near what type of water is the tank located? <br /> .,/A-resh Water D Saline Water ❑ Brackish Water <br /> On which water-body is this marina located? <br /> Highest anticipated water level fluctuation: feel <br /> Has the facility registered its ASTs with the SWRCB? UYes ❑No V <br /> l/A <br /> SPCC Plan available for review on site? OYes -1& ❑ N/A <br /> GPS Lat/Long(if available) Latitude: Longitude: <br /> Is anti-siphon device at highest point of product piping? ❑Yes 0 No -CA anti-siphon device <br /> Is under-dispenser containment present? ❑Yes o <br /> Type of under-dispenser containment monitoring: <br /> Frequency: U Electronic 0 Mechanical 0 Visual N/eo Monitoring <br /> Is there an emergency shutoff(ESO)switch? , Yes 0 No <br /> Number of shutoff valves(not ESOs)from the tank to the dispenser: <br /> Does the dispensing nozzle have a hold-open latch? es 0 No <br /> Please return inspection forms, as you complete them, to Laura Chaddock, Division of Clean Water <br /> Programs, State Water Resources Control Board, P.O. Box 944212, Sacramento, CA 94244-2120. <br /> If you have questions please call Laura Chaddock at(916) 341-5870 or Julie Berrey at(916) 341- <br /> 5871. Please return completed inspection forms for all MFFs by December 31, 2001. <br /> 10123/00 <br /> SWRCB <br />