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saoue�san dwng luawuleluo� oN SGA <br /> k 'h101 s sn0paezetl pUe `su C]I dwn <br /> aosuas aadoad pap `aa/EW `a�ewa S jU9WU/g u0 <br /> a a.iinbei Molapue `aauelsgns snopaeze pyo a94 duuns;uacuu � � <br /> uaa q palsll sdiuns 4 s. qap `aa;eve �e;uv0 eq s/ <br /> re�o,l 4;OU aAey pue luawu►e;uo3 uetaiu _w�iv ao�uoisoadsu� <br /> 31odaa u0t13adsuj-oieaad <br /> _ alma asea�aa a pe4 anei �1Sr) pa;eu6 sa as pail!/enb a ire os <br />• — -_ !1e41 sd <br /> iQ ON/NER/Oso/-RA Tc7R OESGR/PT/ON OF FOLLOW-UP ACTION <br /> it ,�11 ,,tqf . ctiot7s to correspond to appropriate compliance issues from Section 3. <br /> Y4 • <br /> 0 <br /> to <br /> , o <br /> 6. OWNER/OPERATOR ACKNOWLEDGEMENT OF � ' <br /> I have reviewed the results of the designated UST o era <br /> description of the action s t INSPECTION RESULTS <br /> c0 o co <br /> o m <br /> operator inspection report and provided a N o �z <br /> ( ) aken or to be taken to correct an GCol <br /> Name of UST Owner/Opera r rint <br /> y compliance issues discovered. cO <br /> UST Owner/Operator Signa � N m <br /> m v , <br /> y Date Signed <br /> 7• INSPECTION HISTORY <br /> -Z0Z3 m <br /> Has each follow- � <br /> Operator Ins up action of Section 3 from the previous Desi T <br /> Attach pection Report been completed a ^' <br /> documentation verif in appropriately? gnated UST D <br /> 8• RELEASE DETECTION a ro nate service to this report Yes No NA '� <br /> AttachALARM HISTORY ❑ ❑ <br /> a copy Of the alarm � o <br /> Is the history reporV/o <br /> monitoring system 9 to this report, <br /> Has each alarm since m Powered on and in proper operating mode? Yes No NA <br /> (Attach documentation verifyeng as inspection been res Q <br /> Have all containment sum pprO riate ponded to appropriately? <br /> p service to this re ❑ <br /> designated UST o sumps, that have had an alar port.) X <br /> service n technicianperator inspection re m since the <br /> port, been responded <br /> ❑ <br /> ponded to by a qualified ❑ ❑ <br /> x <br /> All answers marked"No"Must be described <br /> by the designated UST operator in Sect <br /> ion 3. <br /> I � <br /> Page 2 Of 4 <br /> CERS =California Environmental Reporting System, ICC = n e -rondo <br /> Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, UST = Undergruul <br /> Storage Tank <br /> UN-111 <br /> www.unidocs.org Rev.10101120 Page I of 4 <br /> iL <br />