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Current UST Site Survey Form <br />r•, rtrnrnin Stare Water Resources Conrroi Board <br />- �Hertnrval' r�L�Hgmr <br />[Other <br />,lgmcy rT S rl p Dam: X 3 <br />C ROcasc mvungan,ur `;r'wnpluncc ,nspccuun <br />Site Information S ceeame:� T �A �r U �`SC�400 U/ STh SGT <br />,,MM: :in IG N. <br />Street Address - Clryf County. U. <br />Fc hN. c. QRenii Gasoline Dotter r¢other. rS � - �Fvt�y-e <br />Ii0k Mammal: <br />Bare Steel CMfr. C.P. CReuorit C.P. <br />CLined —C.P. CCfad CFbcrglass Oodwr <br />" "Walls:".`nrsingte <br />wall CDoubiewall <br />TCGasolim <br />Produce <br />1�Oiec1 <br />Age. <br />C<Syr Q5-10yr 011-15yr Q>i5yr _ <br />upgrade: <br />c1spill COvertilt <br />Q Striker Plate - <br />EII OY <br />i Material: <br />` <br />DWare steel <br />❑Rigid 6beglass LjFeubie <br />Walls: <br />Csingle _ CDouble <br />- <br />Age-- <br />0<5yr C5 -10 -IT <br />QS11-15yr . C>15Yr <br />Connintnmo CDisymse CTurbine <br />CNone .- - - <br />Purnping: <br />CPressure CConvcndonai Sucaon CSuc suedon CGnvrry <br />', <br />T.e�g detection <br />,\x-t._..st .;-cd ,t d= <br />CMIR <br />rel n e ,dmnfxed. ora[ cl� if no release <br />C Sump disperiser=Mi[rttrenc LD <br />- <br />- <br />XS [R (BnndN dLI QSt �hAni, - - <br />CTT (BrarrdlModd 1 <br />OFT (BrincltModel 1 <br />CINT(BnndModel ) <br />CATG (Brsmdt 4odei ) <br />CGW(B=dModet <br />Cvadose(13=6 Sodet <br />CMech. LLD <br />(Brand/Model 1 <br />CIElca LLD (Bmand[Modd <br />L== Lt7Psss...... <br />_ CFaii Ctrrconclusive <br />Damr. <br />r s[ PT* (:IF= <br />CFaii -. Cinconciusive <br />Due <br />r asta1Ro Cpass <br />_ CFail [Rnconclusive <br />Date: <br />Rd==Ina <br />o release suslsecmd (slap remainder of section) <br />Dam of cantmned release - <br />Ca.sc- . <br />r Cphysical damage: CCortasion CMechanica[ faiime Cl Loose Fmthtg- Q Overfill <br />CFaulry installanon Q Strucarral Fwiure <br />Q SprII CCnknoam Mother' <br />_ Bootee: <br />CTank rPioing CDmicnser CSpol <br />- QOvcrrill QUnknown COthar - <br />How - Ie tifed? <br />CLO mxdrod(s) speafy - <br />CC'usuro Removal COther <br />Fsjjrriimjav rrfa=CRcx=(<tyrt <br />COtd(>I yr) <br />CUnknoam - <br />=, rtn` ryy estear <br />CLQ alrzed unk CLoalizcd piping (71-=Iized Disnrnscr :CLvge thernrN etn`'ared arear - COIt-sire <br />(3i9s) Infor=11on provided For this srudy dors not. supersede s=dard reporting mgwrements. <br />