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�i UNDERGRQUND STORAGE TANK <br />�� Site Check/Site Assessment Check!�st <br /><<�'c�,�'� ; <br />Thc purpusc of this form is �o ccnify �hc proper invcstigatiun uf an USTsiic for thc prescncc of a rcicasa 'I}icsc activitics <br />.hall bc mnductcd in accurJancc wiih Ch�picr 173.3611 �VAC. A dc�cripiion of ihc �mrious siivaiions rcyuiring a sitc <br />chccL• or sitc asscsxmcnt is providcd in ihc �uidancc ducumcni.fur USTsi�c chccks and sitc essusmcnts. <br />This Siic ChccWSiic Aiscssmcnt Chccklist shall hc cnmplc�cd and signcd by a person rcgistcrcd wiih the Dcpanmcnt of <br />Ecology io perfonn sitc asscssmcnts. <br />Z'wo copi�s oCthc res�d�s o( thc site chcck or sitc assasmem shoulJ bc includcd with this chccklisc acwrding to the ;e- <br />porting rcyuircmcnts in the guidance dncumcnt for USTsitc chccks and si�e asscssmcros. <br />For Cur�hcr in(ormation about compicting ihis f<�rm, pic�sc comact �hc Dcpartmcnt of EcoloSry UST Program. <br />Thc compictcd chccklist shoul� hc maiicd �o thc li>Il��wing �dJress: <br />Uader��round Storage Tank Section ' <br />� Cepanmenl of Ecology � <br />- Mail Slop PV-11 � <br />, Olympia, WA 9850a.8711 <br />1. UST SYSTEM OWNER AND LOCATION <br />UST CwneqOparaior: <br />Owners Address: 3�D� �'���{� �'�, <br />uea a n 30. <br />E vR�P. _� (,�/-) 9B7iJ 1 <br />r.Y Swe �r� <br />Telephone: �% 1 Z S'�j —j�8� <br />Site 10 Number (on invoice or available irom Etology if tank is regisiered): ��3 � <br />S��elBusinessName: C�f(� �yf //P.l'P1�� F//Q S7F'q�/oh.5 <br />Site Address: <br />G�Y Suie �P�. <br />2. SITE i.HECK/SITE ASSESSMENT CONDUCTED BY: <br />Registered Per.son: <br />Address: <br />Telephone: <br />