Document 3eNkQwYjdeNv7R5B4oN4w6xrD
SIC CODE:
United States Environmental Protection Agency (EPA)
Region 2
290 Broadway
New York, NY 10007-1866
Underground Storage Tank (UST) Inspection Form
J f>L-A,/l_
DATE: 0 /1 'I /2, l
ICIS#: 3601303197
I. Location ofTank(s)
Tribal
Facility Name
s v c..u t... VA Kt..t>, c.A. \.. Ci.NT'i..il.
Street Address
Sou \V\4 f\\Jf...t.J\J
City
State
Zip Code
5VAc:u s. e.,
N'f
\.2...16
County
Noi\l.AA
Phone Number
Fax Number
C3\s) L\l.S - '-fl-( o
Contact Person(s)
N\J lN f'-C\t i'-'1.C
T1M.:>\'t'{'( N C>T-Z., (\\LU- t.C.V.L4&T
IIB. Operator of Tank(s)
Contractor Name
3'same as location 0-)
II. Ownership ofTank(s)
Owner Name
same as location (I.)
Street Address
City County
Stale
Zip Code
Phone Number
Fax Number
Contact Person(s)
UC. Ownership of UST(s) at Other Facilities
Street Address
l1'Do you own UST(s) at other UST Facilities No
City
State
Phone Number
Zip Code Fa,-x Number
County
IfYes, How many Facilities
l...
How many USTs
l
ill. Notification [ 280.22- Subpart BJ
Notification to implementing agency; name
't & l)S:. {_
- State Facility ID# 1 - 0\.-\ LL-,
Date Issued: l'L[o<. l1<..
Date Expires: ,,.J2-l2-,
Any change from previous Notification noted? (OwneflOperatubstance stored/ Substance compatibility?)
IfYes, Describe:
,a\.".,6
y efi( L><
IV. Financial Responsibility [ 280.93(a)- Subpatt HJ
State Fund*
o Private Insurance: Insurer/Policy#
Guarantee
Surety Bond
Letter ofCredit
o Local Government
o Selflnsured
Ji Not Required (Federal & State government, hazardous substance USTs)
*IfNY State, then answer: Is there private insurance for third party bodily injury?
V. Operator Training [ 280.240- Subpart JJ
Is there an individual trained for A and B operator classes?
Name ofClass A Operator bbv11J \)&IJ
Are all operators for class C trained?
Does owner have a list ofdesignated operators currently trained at each facility?
Does owner have proof of operators training or retraining?
Yes I!!"" No o
Yes el' No Yesl'!:I' No Yes!.!" No
Notes:
\_;\l I....)
-rt I"'- 0 --4 tJ d (Z._T""Z,.. @. VA.eiov .,.
Page 1 of 8
!nit/Date
07/31/2019
VI. Tank Information
Tank oresentlv in use
Tank No.
D<lo1)
'"{i
Oc,S-
.
If not, date last used
(see Section XII)
Ifemotv, verify I" or less left (see Section Xll) Caoacitv ofTank foal) Substance Stored Compatibility Records Available?
(Comoatibilitv Demonstrated?) MNTank/UnITTaded
1soo(;
- [),Ht..
-
o lei-a
l.o c> .>" (,
...
-
-
6 /t,
Tank Construction:
Bare Steel, Sti-P3,
Retrofitted sacrificial anode, Impressed Current,
fl
Composite, FRP, Interior lining, Vaulted Secondary Containment? Soil! Prevention f 280.20(c)(l)(i), 280.21(d)l
Double Walled? YI@
u7;u lM.U-0-
6f\u.. 1--'6-'it
"'tJ D If Yes, Last Monthlv Check?
IfNo, LastTriennial Containment Integrity Test? (_
(l.Lc. /U) -
Overfill Prevention (specify type) f& 280.20(c)(l)(ii), & 280.2Hd)l
Last Triennial lnsoection? Saecial Confl.guration: Compartmentalized, Manifolded, Field Constructed, Airport Hydrant System
\-\1...A-
;
\2 f d l \ -
--
-- ---
VII. Piping Information
Pivin,z Tvne: Pressure, Suction
\S L,':"""a,.:) \/
PiQing_ Construction: Bare Steel, Sacrificial Anode, Impressed Current, Flex,
t)w
R\.,
PRP, Double-walled (OW), Non-corrodible piping
Under Dis{l_enser Containment C'UDC"l?
NIA
-
If Yes, installation date?
Date oflast visual inspection/periodic monitoring Pait ofLine RD? YIN Ifabove Y, UDC Double Walled? YIN
IfDW, Last MontWy Check of Annular Space? Ifnon-DW or no monthly check ofDW, last 3-Yr
Containment IntegrityTest?
Page 2 of 8 lniUDate
, Setion Continues to Page 3 07/31/2019
Digitally signed by HIEP
HIEP TRAN Date: 2021.06.15 TRAN
13:39:55 -04'00'