Document pm1YM0GBDnyYZdmDVwqM188nD

COMPLIANCE INSPECTION REPORT FOR UNDERGROUND STORAGE TANKS EPA Region 6 Federal Form FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Physical Address: City, State, Zip: Mailing Address: Facility Representative Title and E-mail: 10 Camel Rock Road Phone: (505) 955-0139 Santa Fe, NM 87506 County Santa Fe 10 Camel Rock Road (Address) Santa Fe (City) NM (State) 87506 (Zip) Will Baca - Store Manager - wilfred.baca@camelrockcasino.com UST Operator: Pueblo of Tesuque/Pueblo of Tesuque Development Corporation Phone: (505) 984-8414 Fax: - Mailing Address: 17486 US 84/285 A Santa Fe NM 87506 UST Contact: Mailing Address: (Address) Will Baca 17486 US 84/285 A (City) Phone: (505) 955-0139 Santa Fe (State) Fax: - NM (Zip) 87506 (Address) (City) (State) (Zip) UST Owner: Pueblo of Tesuque/Pueblo of Tesuque Development Corporation Phone: (505) 984-8414 Fax: - Mailing Address: 17486 US 84/285 A Santa Fe NM 87506 (Address) (City) (State) (Zip) Contact Name and E-mail: Joseph Abeyta jabeyta@pueblooftesuque.org Ryan Swazo-Hinds rswazohinds@pueblooftesuque.org Phone Number: (505) 218-3688 Facility Land Tribally Owned: Yes No Facility Privately Owned/Leased on Tribal Land: Yes No Lead Inspector: Christine Cherrett (EPA) Additional Inspector(s) and Others present: Leonard Sabatino (ENIPC) Summary of Findings and Facility Comments: Present: * Will Baca Manager of Camel Rock Valero * Joseph Abeyta Pueblo of Tesuque Department of Environment and Natural Resources * Ryan Swazo-Hinds Pueblo of Tesuque Department of Environment and Natural Resources Release Detection Records for USTs and piping well maintained Spill buckets and sumps dry and free of debris Overfill devices (ball float valves) could not be verified during inspection Records must contain documentation of water level checks (12 months) Documentation of replacements and repairs must be maintained and available for review Facility in Significant Operational Compliance EPA REGION 6 UST CEI CHECKLIST 1/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO Section A Registration Requirements INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Further Explanation Attached 1. Are all New and Existing Petroleum UST systems registered? (New - 280.22(a); Existing280.22 (a)) Yes No N/A 2. Are all new USTs that contain regulated hazardous substances registered? Yes No N/A 3. Please indicate the number, size, product stored, installation date, and upgrade date for all tanks at the facility? TANK SIZE of TANK PRODUCT NO. (GALLONS) STORED 1 25,000 UNLEADED 2A 12,000 PREMIUM 3A 12,000 DIESEL TANK TYPE SW / DW DW/FRP DW/FRP DW/FRP STATUS Compartment or Manifold Active or TC Indicate associated tank(s) ACTIVE Compartment Manifold ACTIVE ACTIVE Compartment Manifold Compartment Manifold Compartment Manifold Compartment Manifold Compartment Manifold INSTALL DATE 5/2008 5/2008 5/2008 UPGRADE DATE Compartment Manifold Compartment Manifold Compartment Manifold Compartment Manifold Latitude: Degrees: Minutes: 35 49' 25.20" Seconds: Longitude: Degrees: Minutes: 105 58' 30.78" Seconds: GPS Measured At: Input Tank # fill- 2 port. Number of Dispenser's: 2x6 (12 total) marked at facility (detail how this count was made below) Section A Comments: Add converted GPS measurement in Decimal Degrees www.csgnetwork.com/gpscoordconv.html decimal degrees: 35.823667 -105.975217 The installation month varied on different paperwork May or June (used Notification Form date) all indicate 2008. Tank documentation and photos in facility binder "Xerxes". EPA REGION 6 UST CEI CHECKLIST 3/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Significant Operational Compliance Components (SOC) SOC - Release Prevention Section B Standards for New Underground Storage Tanks (Tanks installed after 12/22/88) Further Explanation in Narrative Section B Not Applicable 1. Tank Construction: S-p8 SW DW a. Is each tank properly designed and constructed to prevent corrosion in any portion of the Yes No N/A tank that routinely contains product?(280.20(a)) b. If installed after 4/11/16 is tank secondarily contained? Yes No N/A 2. What is the corrosion protection method for the tanks? S-p8 a. Fiberglass reinforced plastic-FRP (280.20(a)(1)) Yes No N/A b. Tank constructed of metal and cathodically protected e.g. galvantic - STI-P3, metal tank with impressed current system (280.20(a)(2)) Specify: - Yes No N/A c. Metal-fiberglass-reinforced-plastic composite (ACT-100) (280.20(a)(3)) Yes No N/A d. Records available to document that Corrosion Protection is not necessary. (280.20(a)(4)) Yes No N/A e. Other corrosion protection (280.20(a)(5)) Specify: - 3. Have repairs been conducted on any tank? Yes No Tank #: Repair Date: a. Were repairs to tanks conducted in accordance with accepted codes and standards? (280.33(a)) b. Were repairs to fiberglass-reinforced tanks conducted by manufacturer's authorized representatives or in accordance with accepted codes and standards? (280.33(b)) Yes No N/A Yes No N/A c. Were the repaired tanks tightness tested within 30 days of the completion of the repair (280.33(d)) unless inspected, monitored or otherwise tested? (280.33(d)(1, 2, 3)) S-p3 Yes No N/A Section B Comments: Section C Upgrading Existing Tanks to New System Standards Further Explanation in Narrative (Tanks installed on or before 12/22/88) Section C Not Applicable 1 Do the Existing Tank(s) comply with one of the following requirements: a. Are all existing tanks upgraded to meet the standards or do they already meet the stardards for New UST systems?(280.21) Yes No N/A If yes, specify tank type: b. Are all existing tanks upgraded with cathodic protection?(280.21(b))If yes, complete Yes No N/A 2. What method of corrosion protection is used for each tank? S-p8 Yes No N/A a. Metal tank retrofitted with interior lining (280.21(b)(1)) Date Lining Installed: Yes No N/A b. Is lining inspected periodically? (280.21(b)(1)(ii)) Date of Last Lining Inspection: Yes No N/A Metal tank retrofitted with cathodic protection (280.21(b)(2)) c. Type of CP: Yes No N/A If tank >10 years old when CP was added, was a tank integrity test performed? d. (280.21(b)(2)(i) S-p8 Yes No N/A EPA REGION 6 UST CEI CHECKLIST 4/16 March 9th 2017 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Type of integrity test performed: Date: e. Internal Lining combined with cathodic protection (280.21(b)(3)) If CP was not installed at same time as the lining, complete section C.2.d above. f. Other corrosion protection. Specify: Section C Comments: Yes No N/A Yes No N/A Section D Standards for New/Existing UST Piping System (Piping installed after 04/11/2016 must be secondarily contained) (Piping installed after 12/22/88) 1a. For piping installed after 04/11/2016, is it secondarily contained?(280.20) 1b. For piping installed before 04/11/2016 indicate double / single wall Further Explanation in Narrative Section D Not Applicable Yes No N/A Double Wall Single Wall 2. Is piping that routinely contains regulated substances and is in contact with the ground or water Yes No N/A designed, constructed, and protected to prevent corrosion? (280.20(b) new/ 280.21(c) existing) S-p8 3. What method of corrosion protection is used for the piping? S-p8 a. Fiberglass-reinforced plastic piping -FRP (280.20(b)(1)) Yes No N/A b. Non-metallic flexible piping (280.20(b)(4)) Type: Yes No N/A c. Constructed of metal and cathodically protected e.g. coated w/dielectric material, metal piping with anodes, or metal piping with impressed current system. (280.20(b)(2)) Specify: Yes No N/A d. Metal piping without additional corrosion protection measures. (280.20(b)(3)) Specify: Yes No N/A e. Records available to document Corrosion Protection is not necessary. (280.20(b)(3)(ii)) Yes No N/A 4. Are all metal components (flexible connectors, submersible turbine pumps) that routinely contain regulated substances and are in contact with the ground or water designed, constructed, and protected to prevent corrosion? (280.20(B)) S-p8 Yes No N/A a. Constructed of metal and cathodically protected e.g. coated w/dielectric material, metal componets protected with anodes or an impressed current system, contained in dry sumps. (280.20(b)) Specify: dry sumps Yes No N/A b. Metal piping components without additional corrosion protection measures. (280.20(b)(3)(ii)) Specify: Yes No N/A 5. Are all impact valves (shear valves) properly installed (moving parts unobstructed, shear valve properly anchored)? (NFPA 30A Chapter 6 Paragraph 3.9) Yes No N/A 6. Have repairs been made to any piping? Yes No Associated tank # ________ Date of repair ____________ a. Were any metal pipe sections or fittings that released product replaced? (280.22(c)) Yes No N/A c. Was the repaired piping tightness tested within 30 days of the completion of the repair (280.33(d)) unless inspected, monitored or otherwise tested? (290.33(d)(1, 2, 3))S-P3 Yes No N/A Section D Comments: b. Were fiberglass pipes and fittings repaired in accordance with manufacturer's specifications? (280.33(c)) Yes No N/A d. Was 50 percent or more of the piping replaced with DW piping during the repair? Yes No N/A EPA REGION 6 UST CEI CHECKLIST 5/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Section E Spill and Overfill for New/Existing UST Systems Further Explanation in (UST systems installed after 12/22/88 are considered new) Narrative Section E Not Applicable 1. Is each tank equipped with Spill Prevention Equipment to prevent a release of product when the transfer hose is detached from the fill pipe? (280.20(c)(1)(i); 280.20(d)) S-p1 Yes No N/A a. Does the spill prevention equipment have liquid tight sides and bottom (not cracked or broken)? (280.20(c)(1)(i)) S-P1 Yes No N/A b. Spill equipment construction c. For double walled spill buckets, is the spill prevention equipment interstitially DW SW monitored? Yes No N/A d. If not interstitially monitored or if single wall, has the spill prevention equipment been tested within the last 3 years? (Required after 10/13/15 for new/replaced; by 10/13/18 for existing. (280.35) Date: Method: Yes No N/A e. Is the spill bucket free of liquids, so that it will contain any overfill? Yes No N/A f. Has the spill bucket check been conducted every 30 days? (280.36(a)(1)(i) Required by 10/13/2018 Unless exception used, explain in comments g. Has the spill prevention equipment been repaired/replaced since the previous inspection? Replace / Repair Date: Yes No N/A Yes No N/A 2. Is each tank equipped with Overfill Prevention Equipment? (280.20(c)(1)(ii)). S-p2 Yes No N/A 3. Is the Overfill Prevention Equipment designed to: S-p2 a. Automatically shut off flow to the tank when the tank is no more than 95% full? e.g. butterfly valve (280.20(c)(1)(ii)(A)) (device not tampered with or inoperable) Yes No N/A b. Alert transfer operator when tank is no more than 90 % full by restricting flow into the tank (ball float valve) or triggering a high-level alarm (overfill alarm)? (Is the alarm Ball Float Alarm near the fill port? Does it work? If No, explain in Comments) (280.20(c)(1)(ii)(B)) c. Restrict the flow 30 minutes prior to overfilling or alert the operator one minute Yes No N/A before overfilling? (280.20(c)(1)(ii)(C)) d. If ball float valves are used, is the piping system pressurized. Ball float valves are not Yes No N/A allowed for use on suction piping delivery systems (PEI/RP100-2005, Chapter 7.3.3 for New Systems; PEI/RP100-2005, Chapter 7.3.3 for Existing Systems) 4. Alternative type of Spill or Overfill Prevention Equipment being used? (280.20(c)(2)ii)) Yes No N/A Specify: 5. Has the overfill equipment been tested within the past 3 years? Required after 10/13/15 for Yes No N/A new/replacement installation, 10/13/18 for existing installations (280.35) Date: Yes No N/A Section E Comments: During inspection noted different spill bucket types; no replacement repair records in facility binder; follow up e-mail indicates no record available for diesel spill bucket replaced approximately 4 years ago (per Will Baca) SECTION F (installed after 4/11/2016) Section F Under-Dispenser Containment ) (UDC) (Dispensers installed after 4/11/2016) Further Explanation in Narrative Section F Not Applicable 1. For dispensers installed after 4/11/2016 (280.20(f)) or those installed after 10/18/15with IM: Yes No N/A a. Is each new dispenser at a new facility equipped with UDC? b. Is each new dispenser at an existing facility where new pipe (50% or greater) was added to connect the new dispenser to the existing system equipped with UDC? Yes No N/A Yes No N/A C. Is each replacement dispenser at an existing facility where piping (50% or greater) that connects the dispenser to the existing piping is replaced equipped with UDC? Yes No N/A EPA REGION 6 UST CEI CHECKLIST 6/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE 2. Does each UDC sump subject to the 4/11/2016 UDC requirements or installed utilizing IM after 10/13/15 have liquid-tight sides and bottom, and is it maintained free of storm water, debris and regulated substances? (280.20(f)) Yes No N/A 3. If UDC is being used for IM, have the UDC's been tested within 3 (three) years? (Effective for new UDC 4/11/2016 and existing UDC's No Later Than 10/13/18) Yes No N/A Section F Comments: SECTION G (installed after 4-11-2016) Section G Submersible Turbine Pump (STP) Secondary Containment Further Explanation in Narrative Section G Not Applicable 1. For submersible turbine pumps installed after 4/11/16 (280.20) a. Is each new STP at a new facility equipped with liquid tight containment? b. Is each new STP at an existing facility where a new pipe run was added to connect the new STP to the system equipped with liquid tight containment? (280.35(a)(1)) c. Is each replacement STP at an existing facility, where 50% or more of the piping is replaced that connects the STP to the system, equipped with liquid tight containment? (280.35(a)(1)) Yes No N/A Yes No N/A Yes No N/A 2. Does each STP containment sump subject to the 10/13/2015 STP Secondary Containment requirements have liquid-tight sides and bottom, and maintained free of storm water, debris, and regulated substances? (303.D.5.b) Yes No N/A 3. Are the STP sumps used for piping Interstitial Monitoring? 4. Have STP containment sumps used for IM been tightness tested in the last 3 years (10/13/15 new, No Later Than 10/13/18 existing) Section G Comments: Yes No N/A Yes No N/A Section H Operation and Maintenance of Corrosion Protection Systems Further Explanation in Narrative Section H Not Applicable 1. Is the corrosion protection system continuously operated and maintained to provide corrosion protection to metal components of external portions of the tanks and piping that routinely contain regulated substance and are in contact with the ground or water? Yes No N/A (280.31(a)) S-p5 2. Are the cathodic protection systems inspected by qualified testers?(280.31(b)) S-p5 Yes No N/A 3. Was the cathodic protection system tested within six months after installation? (280.31(b)(1)) Date: S-p4 Yes No N/A 4. Is the system tested at least every three years? (280.31(b)(1)) Date: Yes No N/A 5. Does the inspection meet the requirements of a code of practice developed by a nationally recognized association? (280.31(b)(2)) Yes No N/A 6. As outlined in 280.31(b), does the facility have copies of the last two CP inspections? (280.31(d)(2)) Yes No N/A 7. If the UST system has an impressed current, is the rectifier inspected every 60 days (280.31c) S-p6 Yes No N/A 8. As outlined in EPA regulations, does the facility have copies of the last three rectifier inspections? ((280.31(d)(1)) Yes No N/A EPA REGION 6 UST CEI CHECKLIST 7/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE 9. Was the cathodic protection system tested within six months of a repair?(280.33(e)) S-p4 Yes No N/A Section H Comments: SOC - Release Detection Section I Release Detection Requirements for UST System Further Explanation in Narrative Section I Not Applicable 1. Does the facility perform a method of release detection? Check "No" if no release Yes No N/A detection conducted (280.40(a)) S-D1 2. Is the method of release detection capable of detecting a release from any portion of the Yes No N/A tank that routinely contains product? (280.40(a)(1)) S-D2 3. with the manufacturer's instructions including routine maintenance, etc.?(280.40(a)(2)) Is the release detection system installed, calibrated, operated, and maintained in accordance Yes No N/A Does the release detection system meet the performance standards outlined in 280.43 or 4. 280.44? (Check third party certification against equipment or method present)((280.40(a)(3)) Yes No N/A S-D 3 5. Are all USTs monitored at least every 30 days for releases? (280.41 (a)). S-D 5 Yes No N/A Is UST systems subject to the 4/11/16 Secondary Containment Requirements: 6. (Interstitial Montoring) a. Portions of UST system using IM: Tanks Piping Spill Buckets Yes No b. Are monthly records available to verify no leaks to interstice or the environment from tanks? Yes No N/A c. Are monthly records available to verify no leaks to interstice, sump or the environment from piping? Yes No N/A 7. Has Annual testing/inspection of release detection equipment (ATG, probes/sensors, ALLD - simulating lead, vacuum/pressure guages, hand held equipment) been conducted? (280.40(a)(3) required No Later Than 10/13/18 Yes No N/A Section I Comments: Section J Release Detection Record Keeping Further Explanation in Narrative Section J Not Applicable 1. As outlined in 280.34 does the facility maintain all written performance claims and documentation provided by the release detection vendor for 5 years? (280.45(a)) Yes No N/A 2. As outlined in 280.34, does the facility maintain all monitoring results, sampling records, S-D5 equipment testing, calibration and maintenance records, or leak detection equipment repair Yes No N/A records for at least one year? (280.45(b) and (c)) Specify: 3. As outlined in 280.43(c), are all tank tightness-testing records retained until the next test is conducted? ((280.45(b)) 4. As outlined in 280.34, are schedules of required calibration and maintenance for release detection equipment retained for 5 years from date of installation? ((280.45(c)) 5. Are records available to verify water levels in the tanks are checked monthly to 1/8th inch? (280.43(a)(6) Section J Comments: Yes No N/A Yes No N/A Yes No N/A water level in tanks: facility able to view information on RD equipment but records not maintained - this will be included in the facility binder going forward EPA REGION 6 UST CEI CHECKLIST 8/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Section K Release Reporting Suspected Releases Further Explanation in Narrative Section K Not Applicable When a release detection method indicates that a release may have occurred; has the 1. facility notified EPA/State of a suspected release? (280.40(b) and 280.50(c)) S-D4 Yes No N/A Has the facility notified the department of any other suspected release (regulated 2. substance discovered, unusual operating conditions)? (280.50(a) or (b)) Yes No N/A Facility has resolved suspected releases in accordance with procedures outlined in 3. 280.52? S-D4 Yes No N/A Spills and Overfills Has the facility reported, investigated, and cleaned-up any spills and overfills as 1. required by 280.52 through 280.67 Yes No N/A Section K Comments: Section L Release Detection Methods for Tanks (Fill out only the applicable sections, all others can remain blank) Further Explanation in Narrative Section L Not Applicable Inventory Control with Tank Tightness Testing (280.41(a)(1)) S-D5 1. INSTALLED ON or BEFORE 4/11/16 a. Are inputs, withdrawals, amounts in tank recorded daily or on each operating day? (280.43(a)(1)) Yes No N/A b. Is the measuring equipment capable of measuring the level of the product over the full range of the tank's height to the nearest one-eighth of an inch? (280.43(a)(2)) Yes No N/A c. Are inputs reconciled with delivery receipts? (280.43(a)(3)) Yes No N/A d. Are deliveries made through a drop tube which extends to within 1foot of bottom? (280.43(a)(4)) e. Are measurements of water level made to the nearest 1/8 inch at least once a month?(280.43(a)(6)) f. Is the TTT conducted every 5 years as required and is TTT method capable of detecting a 0.1 gal/hr leak rate from any portion of the tank routinely containing product? (280.41(a)(1)) Date of Last Tank Tightness Test: Yes No N/A Yes No N/A Yes No N/A g. TTT conducted following the manufacturer's instructions or third party certification. (280.43(c)) h. Within the 10 year time frame for using IC/TTT? (280.41(a)(1)) Expiration Date: Yes No N/A Yes No N/A 2. Manual Tank Gauging (MTG) (tanks <2000 gal) (281.43(b)) S-D5 Deadline date: a. If tank is >550 gal and < 2000 gal, is tank tightness being conducted every 5 years? (280.41(a)(1)) Date of last tank tightness test: b. Tank size is appropriate for using MTG (280.43(b)) c. Method is being conducted properly (280.43(b)(1) through (5)) d. No liquid is added to or taken out of tank during test. (280.43(b)(1)) e. Equipment is capable of 1/8-in measurement (280.43(b)(3)) f. Within the 10 year time frame for using MTG/TTT for tanks between 550 and 2000 gallons? (280.41(a)(1)) Expiration Date: Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A EPA REGION 6 UST CEI CHECKLIST 9/16 March 9th 2017 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE 3. Automatic Tank Gauging (ATG) (280.40(a)&280.43(d)) S-D5 INSTALLED ON or BEFORE 4/11/16 Make and Model: INCON TS1001 Probe Type: magnetostrictive liquid level probes a. Is the ATG capable of detecting a leak of 0.2 gal/hr leak rate? (280.43(d)(1)) S-D3 Yes No N/A b. As the sole method of release detection, the ATG must test the tank at least once per Yes No N/A month in a manner that can detect a 0.2 gal/hr release with a pd > 0.95 and a pfa < 0.05 (280.40(a)(3)) c. The ATG will generate a hard copy which contains the following: S-D3 i. the time and date of the test Yes No N/A ii. the tank identification iii. the qualitative result either "pass" or "fail" Yes No N/A Yes No N/A d. Type of test conducted intank volumetric leak tests 4. External Release Detection Devices a. General Requirements for Release Detection Devices S-D5 INSTALLED ON or BEFORE 4/11/16 i. Do the RDDs meet the general requirements for construction? (280.43(e)(1) &(6) and (f)(7)-(8) ii. RDDs screened from 1 ft below the surface throughout the entire excavation zone? Yes No N/A (280.43(e) & (f)) Yes No N/A iii. Are the RDDs sealed and locked? (280.43(e)(7) and (f)(8)) iv.Are the RDDs installed in backfill? (280.43(e)(1) and 280.43(f)(2)) Type of backfill: Yes No N/A Yes No N/A v. Are RDDs in the correct number and properly positioned? (280.43(e)(6) and (f)(7)) Yes No N/A vi. Does the facility have the paperwork to confirm that the release detection method was properly assessed? (280.45(a) Required After Oct 13, 2018 Yes No N/A b. Vapor Monitoring (280.43(e)) S-D5 INSTALLED ON or BEFORE 4/11/16 i. Is the regulated substance (or tracer) sufficiently volatile to allow vapors to be detected by the monitoring device? (280.43(e)(2)) ii. Vapor monitoring is not affected by high ground water, rainfall, etc. (280.43(e)(3) iii. Does background concentration in excavation zone interfere with method used? (280.43(e)(4)) iv. Is the monitoring device designed and operated to detect any significant increase in concentration above background? (280.43(e)(5)) Yes No N/A Yes No N/A Yes No N/A Yes No N/A c. Groundwater Monitoring (280.43(f)) S-D5 INSTALLED ON or BEFORE 4/11/16 i. Is regulated substance immiscible in water and have a specific gravity less than one? (280.43(f)(1) ii. Water in the monitoring well is never more than 20 feet from the ground surface? (280.43(f)(2)) iii. Does RDD prevent migration of soils into RDD, and can regulated substance enter RDD in both low and high water conditions? (280.43(f)(3)) iv. If RDD installed in native soil, is hydraulic conductivity greater than 0.01 cm/sec? (280.43(f)(2) Yes No N/A Yes No N/A Yes No N/A Yes No N/A EPA REGION 6 UST CEI CHECKLIST 10/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE v. Can continuous monitoring device or manual method detect 1/8-in of free product? (280.43(f)(6)) Yes No N/A 5. Interstitial Monitoring (280.43(g) S-D5 REQUIRED FOR TANKS INSTALLED AFTER 4/11/16 a. Describe the UST system which uses IM e.g. double walled tank, secondary barrier: Explain: Yes No N/A b. Can the method detect a release through the inner wall of the tank? (280.43(g)(1) or (3) S-D2 Yes No N/A c. Continuous interstitial monitoring by an automatic leak sensing device that signals to the operator the presence of any regulated substance in the space or sump (701.A.6.a) Yes No N/A Method: OR ii. Manual interstitial monitoring every 30 days by means of a procedure capable of detecting the presence of any regulated substance in the interstitial space or sump (701.A.6.a) Specify Method: Yes No N/A 6. Statistical Inventory Reconciliation(SIR)(280.43(h)) S-D5 For Tanks INSTALLED ON OR BEFORE 4/11/16 a. Can the SIR method detect a release of 0.2gal/hr from any portion of the UST System that routinely contains product with a pd > 0.95 and a pfa < 0.05? (280.43(h)(1)) Did the owner/operator receive the monthly report(s) from the SIR provider/ b. vendor within the 30 day monitoring period? (280.43(h)) c. Did the SIR analysis report include the following information: i. the name of the SIR provider and the name and version of the SIR method; ii the name and address of the facility at which the analysis was performed; iii. a description of the UST system for which the analysis was performed; iv. a quantitative statement, in gallons/hr, for each UST system monitored for the month, of the leak threshold, minimum detectable leak rate, and the indicated leak rate; v. a qualitative statement of "pass," "fail," or "inconclusive" for each UST system monitored Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A d. Method Name: Version: 7. Other Method: (280.43(h)) Specify Method: a. Method can detect 0.2 gal/hr leak rate or a release of 150 gal within a month; & meet the 95/5 probability requirement. (280.43(h)) OR S-D3 b. EPA has approved the method as being as effective as Tank Tightness testing, ATG, Yes No N/A vapor monitoring, ground water monitoring, or interstitial monitoring and operator complies with any conditions imposed by the agency. (280.43(h)) Yes No N/A Section L Comments: 12 months of release detection available for review; Records well maintained; INCON Tank Sentinel Model TS-1001 (Franklin Fueling Systems) inventory monitoring and leak detection system for up to 4 underground storage tanks. Advised facility to review fuel throughput as increases occur to ensure maintaining parameters for 3rd party certification EPA REGION 6 UST CEI CHECKLIST 11/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM INSPECTION DATE(S): MAY 4, 2018 FACILITY NAME: CAMEL ROCK VALERO Tribal Land: PUEBLO OF TESUQUE Section M Methods of Release Detection for Piping Section M Not Applicable Further Explanation in Narrative Is release detection performed on the UST system's piping? (280.41(b)) Check the appropriate piping system. Yes No N/A 1. Pressurized Piping S-D5 a. Which of the following methods of leak detection does the facility use for pressurized piping? (280.41(b)(1)) i. Automatic Line Leak Detectors (ALLD) installed (one of the following methods is required on all pressurized lines, regardless of line leak detection method used) (280.41(b)(1)(ii)) Yes No N/A MODEL: VEEDER ROOT 1. Automatic flow restrictor, or 2. Automatic shutoff, or MECHANICAL ELECTRONIC Yes No N/A Yes No N/A AND OR 3. Continuous audible or visual alarm Yes No N/A 4. Is a test conducted every 12 months on the line leak detector which simulates a leak according to manufacturer's requirements? (280.44(a)) Date of last test: 3/12/18 ; 3/21/17 Yes No N/A 5. Are records available for performance test for previous 2 years. (starting 10/13/18, 3 years required) Yes No N/A 6. If Electronic, a 3gal/hr test with a PASS or other rate as specified by Manufacturer annually. (Not acceptable after 10/13/2018) Yes No N/A ii. One other method (280.44(b)) (Only appliable if installed on or before 4/11/2016, must use IM afterwards.) S-D5 1. A line tightness test conducted every 12 months (280.44(b)); Dates of last test: S-D5 3/12/18 ; 3/21/17 Yes No N/A 2. Is LTT method capable of detecting a 0.1 gal/hr leak rate from any portion of the piping routinely containing product? (280.44(b)) S-D3 Yes No N/A 3. If Electronic, is a 0.1 test with PASS conducted annually (280.44(b)) S-D5 Yes No N/A 4. Monthly monitoring? (280.44(c)) Specify Type: S-D5 Yes No N/A 5. If Electronic, is a 0.2 test with PASS conducted monthly (280.44(b)) S-D5 Yes No N/A REQUIRED FOR Piping INSTALLED or REPLACED (>50% TOTAL) AFTER 4/11/16 b. Is Interstitial Monitoring Secondary Containment requirements used (303.D.2.f.i), by either: i. Continuous interstitial monitoring by an automatic leak sensing device that signals to the operator the presence of any regulated substance in the interstitial space or sump Yes No N/A (701.B.4) Must have monthly documentation. Specify Method: OR ii. Manual interstitial monitoring every 30 days by means of a procedure capable of detecting the presence of any regulated substance in the interstitial space or sump (701.B.4) Yes No N/A Specify Method: c. For piping subject to the 4/11/16 Secondary Containment requirements, is all piping interstitial space and/or are all sumps maintained free of water, debris, or anything that could interfere with the leak detection capabilities? (701.B.4.a) Yes No N/A 2. Suction Piping S-D5 a. Which of the following leak detection methods does the facility use for suction piping? (280.44(b)) i. (Safe Suction) No release detection is required if piping is sloped to drain product back into tank and only one check valve is present and located directly below or as close as practicable to the suction pump (280.41(b)(2)) -must have documentation Yes No N/A OR ii. Line tightness test every 3 years? (280.41(b)(2)) Date of last test: Yes No N/A EPA REGION 6 UST CEI CHECKLIST 12/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE OR iii. Monthly monitoring? (280.41(b)(2)) Specify Type: Section M Comments: Yes No N/A Records available for more than past two years - demonstrates a pattern of maintenance for piping RD (LTT and LLD testing) Section N Requirements for Temporary Closure (280.70) Further Explanation in Narrative 1. For UST systems in temporary closure; has the facility: a. If greater than 1 inch of liquids remain, is monthly release (280.70(a)) Specify Type of RD performed tanks and piping: b. If applicable, is the Cathodic Protection being maintained? (280.70(a)) Section N Comments: detection Section N Not conducted? Yes S-D7 Yes Applicable No N/A No N/A NON-Significant Operational Compliance Components Section O Temporary Closure Continued Further Explanation in Narrative 1. For UST systems temporarily closed for 3 months or more, did the owner/operator: Not Applicable a. Leave vent line open and functional? (280.70(b)(1)) Yes No N/A b. Cap and secure all other lines, pump, manways, and ancillary equipment? (280.70(b)(2)) Yes No N/A c. Notify the E.P.A of the temporary closure status (UST-REG-01 form)? (280.70(b)(1)) Yes No N/A d. Perform a tank tightness test within five days after the system was brought back into service after being in temporary closure 3 months or more? (903.E) Yes No N/A 2. For any non-upgraded UST system that has been temporarily closed for more than 12 months, has the owner/operator permanently closed the system? ((280.70(c)) Yes No N/A Section O Comments: Section P Additional Paperwork Requirements Not Applicable Further Explanation in Narrative 1. Is the information on the Notice of Registration form current and accurate? (280.22)) 2. Has an amended Registration form been submitted within 30 days of acquiring a UST? (280.22)) 3. Is a copy of the current registration form kept on-site or at the nearest staffed facility? (Not Required.) 4. Has the owner/operator submitted the following information to the department: a. Registration form for all UST systems, including installation certification and installer verification for new tank systems (280.22) b. Reports of all releases, suspected releases, spills and overfills, and confirmed releases (280.34(a)(2)) Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A EPA REGION 6 UST CEI CHECKLIST 13/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE c. Descriptions of corrective action plans, site characterizations, free product removal investigation of soil and groundwater cleanup, and corrective action plan Yes No N/A (280.34(a)(3)) d. Notification before permanent closure or change-in-service (280.34(a)(4) Yes No N/A e. If new ownership, has a notification of ownership change been submitted within 30 days of acquiring a UST? (280.22)) Yes No N/A f. Has notification of a change of storage to regulated substances blended wih greater than 10% ethanol or greater than 20% biodiesel been provided to agency 30 days Yes No N/A before beginning storage? (280.32(b)) 5. Has the owner/operator maintained the following documents: a. Results of site assessment conducted at permanent closure (280.34(a)(5) Yes No N/A b. Documentation of UST system repairs (280.34(b)(3)) Yes No N/A c. Documentation of the type and construction of the tanks, piping, leak detection equipment, corrosion protection equipment, and spill and overfill protection Yes No N/A equipment? d. Assessment of suitability for groundwater or vapor monitoring as release detection method. Retain while in use. (Copy of assessment must be available as of 10/13/18) Yes No N/A (280.45(a)) e. Three year testing of release prevention equipment and containment sumps, and inspection and/or testing (ball floats, and overfill protection devices). Retain for three Yes No N/A years. (280.35(c)(1) f. Annual testing of release detection equipment. Retain for 3 years. (280.45(b)(1) Yes No N/A g. Checklists for Monthly walk thru inspections. Checklists contain dates, findings and actions taken. Retain for 1 year. 280.36(b) Yes No N/A h. Annual walk thru inspection checklists for RD. Retain for 1 year. 280.36(b) Yes No N/A 6. Was the facility able to provide the records in a timely fashion as required by the inspector? (280.34(c) Yes No N/A Section P Comments: Previous notification form dated 2009 - updated form submitted; Questions regarding 1K UST noted in 2009 notification; No documentation for spill bucket repair approx 4 years ago ; Noticed different LLDs no info for review ; Kachina Petroleum has some documentation of original installation Section Q General Requirements Not Applicable Further Explanation in Narrative 1. Are the products being stored compatible with the materials or liner in the UST system? (280.32) Yes No N/A 2. Documentation of compatibility for fuel with >10% ethanol, >20% biodiesel, or another fuel designation by implementing agency. Retain as long as fuel is used. (280.32(b)(2)) Yes No N/A Section Q Comments: Section R Financial Responsibility Not Applicable Further Explanation in Narrative 1. Can the owner/operators demonstrate financial responsibility for taking corrective action, including 3rd party liability? i.e: how is he going to pay for the cleanup of a release? Yes No N/A (280.94 -280.99)Records - 280.111 What type of financial responsibility is used? Explain: insurance 2. If Insurance, list company and contact: Ironshore Specialty Insurance Company Policy Number: 002808401 3. Insurance Mailing Address: 75 Federal St, Boston, MA 02110 Contact Number: (646) 826-6600 E-mail: toby.smith@ironshore.com Effective Date of Coverage: 7/01/2017 Expiration Date on Policy: 07/01/2018 Retroactive Date: - Confirmed Released Policy: Suspected Release Policy: EPA REGION 6 UST CEI CHECKLIST 14/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE 4. Financial Assurance Documentaion a. Copy of Signed Certification of Financial Responsibility available and current. b. Copy of signed Certitficate of Insurance or Endorsement. Yes No N/A Yes No N/A Section R Comments: FR expires 7/01/2018 ; followed up in August and policy is renewed Section S Physical Documents Obtained Not Applicable Further Explanation in Narrative If any documents, printouts or other materials were obtained from the facility, owner or operator explain below what was obtained and add to Inspection Packect and document in attachments. Section S Comments: Copy of the 'Certificate of Insurance (Federal)' provided 2 pages included as Attachment 4 Operator Training DESIGNATED CLASS A AND CLASS B USTOPERATORS FOR THIS FACILITY: Class A UST Operator: Mailing Address: Class B UST Operator: Mailing Address: Class C UST Operator: Mailing Address: Class C UST Operator: Mailing Address: Comments on Operator Training: (Address) (Address) (Address) (Address) Phone: Phone: Phone: Phone: Date Certified: (City) (State) Date Certified: (City) (State) Date Certified: (City) (State) Date Certified: (City) (State) N/A (Zip) (Zip) (Zip) (Zip) EPA REGION 6 UST CEI CHECKLIST 15/16 Note: All questions are to be answered. If unable to determine, write `unknown' and explain in narrative. Use narrative / summary of findings area to describe all areas of concern in greater detail. R6USTCEIForm-001-R02 J)igital Image Log FID#: lo279NM I INSPECTION DATE(S): IMAY 4, 2018 FACILITY NAME: CAMEL ROCK VALERO Camera type and IOI LUMIX 1543 Image File Date Time # # ##/ # #/ #### AM / PM I 136 5/04/2018 9:03 A,\1 0 PM D 2 137 5/04/2018 9:14 AM 0 PM D 3 138 5/04/2018 9:14 AM 0 PM D 4 139 5/04/2018 9:16 AM 0 PM D 5 140 5/04/2018 9:17 AM 0 PM D 6 141 5/04/2018 9:19 AM 0 PM D 7 142 5/04/2018 9:21 AM 0 PM D 8 143 5/04/2018 9:22 AM 0 PM D 9 144 5/04/2018 9:23 AM 0 PM D 10 145 5/04/2018 9:29 AM 0 PM D II 146 5/04/2018 9:32 AM 0 PM D AM 0 12 147 5/04/2018 9:40 PM D 13 AM D PM D 14 AM u PM D Orientation Photographer N/FJS/W/Down Description NW c.cherrett tank pit overview with facility signs down c.cherrett ATG portal: regular/unleaded down c.cherrett sump: regular/unleaded clean & dry down c.cherrett sump: premium clean & dry but more corrosion down c.cherrett sump: premium piping collar chip down c.cherrett spill bucket premium down c.che rrett spill bucket diesel (different than others) down c .cherrett tank ports: ballfloat bung very corroded down c.cherrett LLD diesel ; type and serial number down c .cherrett dispenser 1/2 example ofpiping & ftex connect0<s down E c.cherrett dispenser 3/4 example of piping & ftex OOOOeciOfS c.cherrett release detection INCON TS 1001 I certify that the digital images for this inspection were taken and archived according Lo EPA standard operating procedures and protocols. The digital images have not been altered and are a fair and accurate representation ofobservations made during the inspection. I certify that t he~ital media has been in my possession throughout the inspection trip and that I transferred the digital images Lo a CD-R. [{jYes 0 No Inspector: EPA REGION 6 UST CE! CHECKLIST 16116 Note: All questions are to be answered. If unable to determine, write 'unknown' and explain in narrative. Use narrative I summary of findings area to describe all areas ofconcern in greater detail. R6USTCEIForm-001-R02 FID #: 0279NM FACILITY NAME: CAMEL ROCK VALERO INSPECTION DATE(S): MAY 4, 2018 Tribal Land: PUEBLO OF TESUQUE Inspection Packet A0: Final Inspection Report A1: Facility Diagram Attachment A2: Digital Images Attachment A3: Observation Report A4: See Section "S" R6USTCEIForm-001-R02 FID# 0279NM Inspection Date 5/04/2018 Facility Name CAMEL ROCK VALERO FIGURE 1 - SITE AERIAL A1-1 FID# 0279NM Inspection Date 5/04/2018 N Facility Name CAMEL ROCK VALERO CAMEL ROCK VALERO STORE 6 dispenser islands / doubled 12 dispensers COMPARTMENT UST (2) 12,000 GALLONS Pump Fill Port ATG Port FIGURE 2 - TANK DIAGRAM CAMEL ROCK VALERO Facility ID: 0279NM Vapor Recovery Port Interstitial Monitoring Tank Vent Regular NE Premium Diesel Regular<10% Tank Construction: DW FRP Line Construction: DW FRP Ball Float Valve _ _ _ Double Wall NOT TO SCALE A1-2 FID# 0279 NM Facility Name CAMEL ROCK VALERO Facility Address 10 CAMEL ROCK ROAD, SANTA FE NM 87506 Photographer(s) CHRISTINE CHERRETT Inspection Date 5/04/2018 Tribal Land PUEBLO OF TESUQUE ATTACHMENT 2 - PHOTOS A2-1 FID# 0279 NM Facility Name CAMEL ROCK VALERO Facility Address 10 CAMEL ROCK ROAD, SANTA FE NM 87506 Photographer(s) CHRISTINE CHERRETT Inspection Date 5/04/2018 Tribal Land PUEBLO OF TESUQUE Checklist Log Photo # 3 Camera File Photo # 138 Direction/Orientation DOWN Time 9:14 AM Description: SUMP - REGULAR/UNLEADED; CLEAN AND DRY A2-2 FID# 0279 NM Facility Name CAMEL ROCK VALERO Facility Address 10 CAMEL ROCK ROAD, SANTA FE NM 87506 Photographer(s) CHRISTINE CHERRETT Inspection Date 5/04/2018 Tribal Land PUEBLO OF TESUQUE Checklist Log Photo # 4 Camera File Photo # 139 Direction/Orientation DOWN Time 9:16 AM Description: SUMP - PREMIUM; CLEAN AND DRY THOUGH EXIBITING MORE CORROSION THAN UNLEADED SUMP A2-3 FID# 0279 NM Facility Name CAMEL ROCK VALERO Facility Address 10 CAMEL ROCK ROAD, SANTA FE NM 87506 Photographer(s) CHRISTINE CHERRETT Inspection Date 5/04/2018 Tribal Land PUEBLO OF TESUQUE Checklist Log Photo # 10 Camera File Photo # 145 Direction/Orientation DOWN Time 9:29 AM Description: DISPENSER 1 / 2 - PIPING SET UP & EXAMPLE A2-4 FID# 0279 NM Facility Name CAMEL ROCK VALERO Facility Address 10 CAMEL ROCK ROAD, SANTA FE NM 87506 Photographer(s) CHRISTINE CHERRETT Inspection Date 5/04/2018 Tribal Land PUEBLO OF TESUQUE Checklist Log Photo # 1 Camera File Photo # 136 Direction/Orientation NW Time 9:03 AM Description: FACILITY LAY OUT - TANK PIT AND DISPENSERS A2-5 THE UNITED STATES ENVIRONMENTAL PROTECTION AGENCY UST/SOLID WASTE SECTION (6MM-XU) 1445 ROSS AVENUE DALLAS, TX 75202-2733 Tel: 214-665 - 7342 FAX: 214-665-7263 Attn: CHRISTINE CHERRETT INSPECTOR OBSERVATION REPORT FOR INDIAN COUNTRY UST SYSTEMS OWNER AND/OR OPERATOR NAME: PUEBLO OF TESUQUE FACILITY NAME: CAMEL ROCK VALERO IFID# 0279NM ADDRESS: ROUTE 42, BOX 360-T ADDRESS: 10 CAMEL ROCK ROAD (EXIT ON US 85/284) CITY,STATE,ZIP: SANTA FE NM 87506 C!TY,STATE,ZIP: SANTA FE, NM 87506 CONTACT PERSON: TEL: IEMAJL: PERSON(s) PRESENT: W ' \,, l ,Ac_ A:. TEL: 5o> 'f ~ 0I~~1 EMAIL: D No deficiencies observed at the conclusion ofthis inspection. D 1:he above nan;ed facility was inspected by a duly authorized re resentative f h EPA mspector s observations an<l/or recommended corrective :ction. "tho ti e United ~tates Environmental Protection Agency (EPA) . The following are the s, wt m1 estones to e met: \} :t: ~\ ?'-\ 0 \) ~ f=" \'-'\... 8&Ul (>ML/VI 6/tvt ~~ V~\J~ NOi \JtSt~\..~ 0 ./2_ \) ell { ~( e-o A-r AF'J..., \'<J 1NI /;11 ~[;(OJ'l (J s '""'"'.S ;,;-,po 0 (Z~~/\S.~ 0 Bi'\~.Cf\d ti R._.(3(0 /'UP s FO~ }AN'?J ;\ND -kv\.. p~s AN.9 f,Af evL-- ....iA '1-7 N Pl! A/etJ V~lf'\-( "1\(},..; 1'-h..-'-l 11-lfUJ Lt&tf ftA.( Does WdT f;/((eeJ) fl\OAJ~ G./t;l.M:;Vs ,__ ~oMM e1v oev ~- ~ 0 Poe V....M 12/\.fl W.Ai'e\t._ 1/\/ -Jf\,.I /GS' C) ~5EJLvA=nd;V~ ; 0\.1\ (L l tJ (:r lN5 f~cnd,tV A'"l& .E?)W 0 II v/A 7fDl.. 1rv T>WK_ 0" 0 5 v\. 6 fv'I. l '( u.,f () A-;-E"l:? tJ pi<..fi:=il(/;J ~ .s VI... ~,Al\ l l f..._~f:A1 f2... .0oL4_/Vl ~AJl7T' d tV ~ f3"JI\ /Z L- Cc:Jrz-r.J .S ( /)J&{eL- z ) 51/L-v ~c,t:.e7' p I ~""'Y]-6 /V"r rfAN d77-I-!-':">Z. JPlE:: -11-h!:Jl.~ ~ ~fir 0 /2.-0 S -' ! ! s v0 ~l PtSPE:N~ ~ VI tatlG {)J/ f'1ft (A-govt.. If E?V2- v.1tv You can fax the documents to (2 14) 665-7263 Attn: CHRISTINECHERRETT If OU or you can call me at (21 ) _ . Y have any questions at all, please contact me at 4 665 7342 @epa.gov Name of Owner/Operator representative: O U /1 II fl t!-// ~ (Please print -- I ~/ <-- ~ ./ -- ~ ~t- gn"llt' t1Te1 Name of EPA Representative: CHRISTINE CHERRETT (Please Print) ~ -d- /'A~ t. nL-<- "" (Signature) ~ Date of Inspection:MAY 4. 20 1a Start Time: C/ : (}0 C\.. (Military Time) Completion Time: 10 . J) ' -(MilitaryTime) R6USTCEIForm-001-R01 ,,~,, IRON StiOI~ f: ,\ l.ilw 11~ \luu1 al ( : ,ll 11 p; 1; 1 ~ CERTIFICATE OF INSURA~CE (Federal) Name of Covered Location: Came l Rock Address of Covered Location: 10 Camel Rock Road, Santa Fe, NM 87506 Policy Number: 002808401 Period of Coverage: July 1, 2017toJuly 1, 2018 Name of Insurer: lronshore Specialty Insurance Company Address of Insurer: 75 Federal St, Boston , MA 02110 Name of Insured: Pueblo ofTesuque Development Corporation Address of Insured: 17486 A Highway 84/285, Santa Fe, NM 87506 CERTIFICATION : 1. lronshore Specialty Insurance Company, the Insurer, as identified above, hereby certifies that it has issued liability insurance covering the fo llowing underground storage tank(s): Facility ID Facility Name and Address Camel Rock; 10 Camel Rock Road, Santa Fe, NM 87506 Number of Tanks 3 for taking correct ive action and compensat ing third parties for bodily injury and property damage caused by accidental releases in accordance with and subject to the limits of liability, exclusions, conditions, and other terms of the policy; arising fro m operating the underground storage tank(s) identif ied above. The lim its of liability are $1,000,000 each occurrence and $1,000,000 annual aggregate, exclusive of the legal defense costs, which are subject to a separate limit under the policy. Th is coverage is provided under 002808401. The effective date of said policy is July 1, 2017. 2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1: a. Bankruptcy or insolvency of the insured shall not relieve the Insurer of its obligations under t he policy to w hich this certificate applies. b. The Insurer is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or a damaged third party, with a right of reim bursement by the insured for any such payment made by the Insurer. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 40 CFR 280.95-280.102 and 280.104-280.107 . c. Whenever requested by a Director of an implementing agency, the Insurer agrees to furnish to the Director a signed duplicate original of the policy and all endorsements. d. Cancellation or any other termination of the insurance by the Insurer except for nonpayment of prem ium or misrepresentation by t he insured, will be effective on ly upon written notice and only after the expiration of 60 days after a copy of such written notice is received by the insured. Cancellation for non-payment of premium or misrepresentation by the insured w ill be effective on ly upon written notice and only after expiration of a minimum of 10 days after a copy of such written notice is received by the insured. e. The insurance covers claim s otherwise covered by the policy that are reported to the Insurer w ithin six mont hs of the effective date of cancellation or non-renewal of t he policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occu rrence that co mmenced after the policy retroactive date, if applicable, and prior to such policy renewal or term ination date. Claims reported during such extended reporting period are subject to t he terms, conditions, limits, including li mits of liability, and exclusions of t he policy. hereby certify t hat the wording of this instrument is ident ical to the wording in 40 CFR 280.97(b)(2) and that the Insurer is eligible to provide insurance as an excess or surplus lines insurer, in one or more states. / . - _.,,.- /. _ /;.../ .... -- Authorized Represent ative of lronshore Specialty Insurance Compa ny Toby Sm ith Vice President, Authorized Representative of lronshore Specialty Insurance Company 28 Liberty Street, 5th Floor New York, NY 10005 Pag~2of .:!