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N a Fuel Storage and Piping Inspection "t <br /> State W..r Resources Control Board, Clean Water. rams <br /> (Facility Information I `IVB t ll\ �� w 1 Y1 <br /> Facility Name _ <br /> Facility Physical Address tU � t U 01 <br /> Facility Telephone <br /> County_ o� <br /> NO I <br /> Facility Owner <br /> Owner Mailing Address <br /> owner Telephone 1 `' " <br /> Facility I.D.# ^ t ��;[0• �% >Private Ownership ❑Gov't Ownership <br /> P&z) 1 6 -7 ,? 4 Inspector Information <br /> Agency Conducting Inspection 1 la �y Lt, � J <br /> Phone Number <br /> �i <br /> Inspector's Name �e i <br /> Date of Inspection ` <br /> General Site Information <br /> Near what type of water is the tank located? <br /> resh Water ❑ Saline Water ❑ Brackish Water / <br /> On whi li water-body is this marina located? <br /> 9 t !11/la-q lV 'l P (yla�i'i1/�� <br /> Highest anticipated water level fluctuation: <br /> rl feel <br /> es ❑No O NIA <br /> Has the facility registered its ASTs with the SWRCB? IP6 <br /> �/I� <br /> 0 0 N/A <br /> .p�N <br /> SPCC Plan available for review on site? Dyes !7� <br /> GPS Lat/Long(if available) Latitude: <br /> Longitude: <br /> Is anti-siphon device at highest point of product piping? ❑Yes ❑No 0 No anti-siphon device <br /> C�o <br /> Is under-dispenser containment present? 0 Yes // <br /> Type of under-dispenser containment monitoring: <br /> Frequency: <br /> L1 Electronic 0 Mechanical C]Visual l Monitoring <br /> Is there an emergency shutoff(ESO)switch? <br /> CXes 0 No <br /> Number of shutoff valves(not ESOs)from the tank to the dispenser: C <br /> Does the dispensing nozzle have ahold-open latch? <br /> es ❑No <br /> Please return inspection forms, as you complete them, to Laura Chaddock, Division of Clear,Water <br /> Programs, State Water Resources Control Board, P.O. Box 944212, Sacramento, CA 94244-2120. <br /> 16) <br /> if you have <br /> Pleaseeetuorn coplease <br /> mpletedlinspection forChaddock <br /> ms fortal9l MFFs by DeOCembeJulie <br /> r 36errey at(916) 341- <br /> 2001 <br /> 5871. <br /> 10123!00 <br /> SWRCB <br />