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3. 'fANK INFORMATiON <br />t. Tank 10 Number (as registered wi�h Ecology): <br />9. Tank capaciry in galions: � ��Q <br />4. <br />2. Year installed: � � �j b _ <br />4. Last substance stored: /.9��. <br />ON FOR CONDUCTING SITE CHECKI.iITE ASSESSMENT <br />Check one: <br />� Investigate suspected release due to on•si;e envircnmental contaminalion <br />Inves�igate suspeaed release tlue to otl•site enviwnmental cornamination <br />Extend iemporary closure of UST system lor more ihan t2 monihs <br />UST system untlergoing change•in•service <br />__ UST system permanently closed•in•olace <br />UST system Germanenily closed wi�h tank removed <br />Requiretl by Ecology or aelegated agenc� ;or US7 ;ystem closea before DecemCer 22. 1988 <br />Olher ;describe): <br />5. CHECKLIST <br />E;reh itcm of ihc ii�llaa'in, chccklist sh:dl hc ini�i:dcJ by Uic person rc__istcrcd �vith thc Dcp�rtmcnt of Ecology whosc <br />iignaiurc appcan bcluw. I � <br />�- - <br />Yss tia � <br />L Has the site ch?ck/site assessment been conducted acccrdina to applicable procedures spec:tied in ihe UST <br />site check/site assessm=m guitlance issued by !he Decartment ct Etology? � I � <br />' <br />� 2. Has a release irom ���2 UST system oezn ccnlirmea? <br />i <br />NOTE Ownerslaper•,mrs must repoa all conlirmed releases to ihe Cepanment ol Ea�logy or delogarcd aqency wilhin 24 <br />. �iours. — . _. <br />, I <br />♦ <br />3. Are �he results ol ;he si�e checklsne assessmem enc:osetl wuh ibls checklist? � � <br />N07E: iwo copies o! (ho slm cheeklsirc- assessment resW(s mus� be suomitled to tDe Departmenf ol Ero�ogy according ro ��a <br />� I <br />« porting �equiremmts specilied in �be UST sife c�ecklsite assesamem guidance. <br />! licre6y cerrij}� rheu / hm•e heen in rc�yinnsrble c/mr�e u% per�omiing rhe sire cherk/.riie �u'.�c^menr describeu abore. <br />Pcrsons submiuing f'alse inf'omrcuiun cvc snhjrc! ro prnnlrict undcr Chtrprcr 173.3(0 1�!-IC. <br />.I <br />� <br />��,91 -� <br />p.�• sq w�e a <br />6. OWNEH'S SIGNATURE <br />��. �� Q�l� <br />. <br />V pagd <br />ECYO�P�Se I��NQ ' <br />L.' <br />