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DESIGNATED UNDERGROUND STORAGE TANK OPERATO ] D -� <br /> R VISUAL INSPECTION REPORT w <br /> 4 aa, "�m-mow,.w.wa.nr x,myI„•IDSALAOPoy Ya DESIG STORAGE TANK OPERATOR VISUAL IN6PEGTION REPORT <br /> Aw"^a�'^Pr ormaarama VIO. ramp? ® NATED UNDERGROUND STO <br /> ^'"anmaa anum vm..rea, "P"N Pom a/a•y�r.RM 77 <br /> HISTORY Payon <br /> nam a rm�raepe YLERa ID L FALILRYINFORMATION D•malLnbnWeUST DPerelar <br /> N 10-19-2D2o <br /> 'w,r,w ,,,er a.ma.mmA'P'O°e"-Bb bbarts� )rBBvonea l^apvreP ® ❑ awed. <br /> ® Name fswm aFaarynwre arpaA.DwpeuevRvax) Zlp epee <br /> ^-a�,�„ a •,a„",re^a ^'m`" ❑ �,ODOs�relnaDe� <br /> uub.-^.m..«iwx,.uwnsxma„r •M` • • 95205 <br /> br mraneeusr a""'^•aRr/wwnmar room inaPmlan. r mmeya aealriea usr M p 2512exateNw rd. <br /> mzareaax ub•vn.a aay aerra'a 'eN+e conmmmwa rxamr•la•^ry^•'•ar peyraaa r^ 16 DESIGNATED UNDERGROUND STORAGE TANK OPERA TOR INFORMATION <br /> la ore mmalmwmaumP tree Dream UNDERGROUND 3T0 wrer ^'rOW^ pwaualm �mnmce,^wamrs Nmrm atDssgrulae uarovwemrryAn®anwnmam la carREeava.) 559686-2977 Ea. <br /> RAGE re<'awem sea^^x Devid Tumor <br /> L°malmrenesumPlDmn depdaam na:emn„s TANK SYSTEM INSPECTION <br /> Ler°"rzrr°'ra ILL e•Nsc°Y°"ErW'•°°"°aI' ( <br /> Yub6a 8788650-uc 61&2021 - 4 <br /> N ? <br /> ❑ ❑ canminrrRm Sr 0. Y IIL COMPUUWCEEIInUUES A, <br /> ❑ ❑ Mermrer^rxm n va a•wNewmrmeewgwamnin vrearrim mlwww <br /> cl 10 <br /> Are aa•enamain anrrmimrNrtymn IaealNm ❑ 2. �— <br /> mtlmaWllnPmanwneebfeyrmgPai .aM haze^uam able ne mdmN^Rwaurryy/ ❑ 3. — <br /> TANKID nom? ® 4 — <br /> 91 ® ❑ DSL I. <br /> mom en wPerreeaoezmmsrm? ® ❑ ® I <br /> 6. <br /> TANKm 87 ❑ I <br /> 7. <br /> 91 ® Cl DSL 8. <br /> la Ne Ml r'aP•xuraN on theNpye? ® ❑ ® I <br /> TANKID 67 9. <br /> 91 ❑ C 10. <br /> is ne vndorPNww ® ClDSL 77. <br /> 112 °81gerCO"rel^ mlo dept¢,arana:arda,m aeo ❑ C 2' <br /> Y N N N.CERTIFlCATK)N MY DESIGNATED UST OPERATOR CONDUCTING TNIS INSPECTION <br /> 3/4 ® El C, Ur'aa•4trPa^aerconmKKrranlN I llmeby urrWy tlmt the viaW emPotlPe was Pdamed I.-comiNlance MN CaIKanW CDdeWRagulatl°rm,title 23, <br /> ® ❑ ❑ ❑ ❑N tliviairm 3,ehaPbr l6,seetlon 2T18aM alltlw infonllatlP•r lwaaidad Morin is aceunb. <br /> ❑ ❑ ❑ ces.gnarea usr oceramrsgamam ' <br /> ❑ ClC <br /> 0 c ❑ ❑ C <br /> Are ansmrsNainntbraNtlm ❑ ❑ C V. OWNER/OPERATOR DESCRIPTION OF FOLLOW-UP ACTWNS <br /> m10ar4mPermercorq; ❑ ❑ ❑ aPiawm lisNdmaarmrm,Ipwa.naminareedemyeon wore musrwrm.m'wrmlmn,wmmrrmn,NLon«tmeiaRmmne nunreermm net <br /> 11deNaaleaxxneaaeieatoagL ❑ C .ePGrda wdh dra Nanpsrx'na me emmuerwaiaarr.:sa'amoaame inawearl m. <br /> Has ne X. TESTING TENANCE ❑ 13 C 1• <br /> aroniaNu,g sy Ta'n ceniacation Been AND MAIN ® ❑ C 2. <br /> Has ne spM eoraainwlesnn � I^ Past l2 moons? Y N NA DATE LAST <br /> Has ne ow:r(Il Prevention P been PPmPmmd wtlnin Me Pazt 12 momma? PERFOPMEI 3• <br /> Haa neaePb equiPrrentiazpedgn peen mmPlNea wanm ne ® ° 5-10-20 4. <br /> neanwmainmenttppng Ween PPmPlMetl wN,in Pant 3a mbntlm? ® ❑ 5-10-20 5. <br /> Has nafank pghhNss teeerg peen compmNd wghin th va•I]a momma? <br /> Has ne line lghnega teauag peen reaaired timapamm? ® ❑ ❑ 4-11-19 6. <br /> Oma. aired /maimenan wC4A10ask w ro ft ra°mmd tinNlrarnea? ® ❑ ❑ 7/19/18 7' <br /> rest/MaimenalKe Ntm wimin aired nmepa 13 ❑ ❑ <br /> me.uat tesknein ❑ ❑ ❑ 8. <br /> lest/Maildenarme: N^NKe dNns DeMly. <br /> Test/MaiMenelme: 9• <br /> ieat/MantenanPe: O® 4-11-19 10. <br /> rest/MaintenalKe: 13 C311. <br /> TwlmM iNene_ <br /> ❑ ❑ 12. <br /> U E3 W. OWNER/OPERATORACKNOWLEDGMENT OF COMPLIANCE IS SUES <br /> Have atl pldll'idwk Par/ormme NdNy mnvroyea tlutias receFACIL reEM Lpaired roLuOYEE TRAINING ❑ ❑ Ihave rtvi ee°Ddislaovele�dPL1ANCE 1S8lIFS"and PPDvldedatleaedptl°n in seetl°n V.oftln aetla118kan MtD De gkeO <br /> 1111'emNoyee trainn9 whhn the pas112mDDtps? Y R Name PtU5(Oa'rlar/Operator(PnnO ST gmer/Operelar 3ipneWre Dale Sgnetl <br /> cm - ...rAnmtlrn A+bm D=Madfimm•USf.lAtlamwtlWawNiLm.tllrvGaul C4a C—d <br /> 04M i� --�--- ---___ <br />