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Current UST Site Survey Form <br /> California State Water Resources Control Board <br /> s tic ncv Information Insneaar K / f �(,( /(/ j Agcncy - �- _ hate: <br /> Reason for <br /> c umrval QRrrratr p Rdcuc:nvcsncauon p('umphancc inspection <br /> in_nectian. <br /> pOthcr <br /> Site Information Sit,vre. 14 D 19 R 7— <br /> ,,,I'tress: ,313 3 a A r 7` 126e, - <br /> Strect Address City _ L Cuunty <br /> Facility : C3 ) <br /> Retail Gasoline Outlet pother Rft i, D,45j 2 ^A— —� <br /> .yetem information )< <br /> Ta k Mammal: ���rrrBare Steel ❑Mfr.C.P. ❑Retrofit C.P. ❑Lined-C.P. CI r_-Fiberglass ❑Other <br /> Walls: ,�7single watl r,Double until all,/ <br /> Product '❑`Gasoline Xeml 'yC t.oAs t-e <br /> Age: p<5yr p5-loyr p11-15yr )el <br /> Syr <br /> Upgrade: ❑Spill 00vertill Cl Striker Plate <br /> Pioina <br /> Mammal: aro steel QC.P. - )Rigid fiberglus pFlezible <br /> Walls: *ngte ❑Double <br /> Age: p<5yr Q5-10yr ❑I1-1 Syr >ISyr <br /> Contumnene QDispcnser ❑Turbine �kne <br /> Pumping: pPr-sure Conventional Suction` QSafesucoon X-viry <br /> T eak Detection j,'l <br /> s e[ho�( 1 t 1 'd ei ed +[ loner.r a rclea<e <br /> �rvtlR p Sutrtp dispenser rnntammmit LO pSIR(BnndfMcdel 1 �/ <br /> QTT(Bnnd/ModNF- <br /> cl 1 OPT G-- (�J c' H �"" 1 <br /> PINT(Brand/Model 1 ❑ATG lBrand,'vtodel <br /> QGW(Brand/Model I pvadose(Bnnd:'Model 1 <br /> QMech.LLD(BrandlModel 1 ❑Elect.LLD(Brand/Model�/ p —7 1 <br /> Las= Pass ❑Fail ❑Inconclusive Date: 3_ T ( / <br /> Last P'i'! ❑Pus CFail ❑Inconclusive Dam: <br /> I s.t sl ? ❑Pus ❑Fail Qlnconclusive Date: <br /> Release [nCorma[ion y_ _ �q <br /> pNo release suspected(skip remainder of section) Dale of confirmed release <br /> Cause: ❑Physical damage ❑Corrosion ❑Mechanical failure G Loose Fining 0 Overfill <br /> pFauiry installation `J❑ Structural Failure 0 Spill JLnknowT QOthcr <br /> Srr�; )Tank (Piping oispenser pSpJl ❑Overfill C7 Unknown QOthu <br /> en <br /> Haw dufieJ? QLDmathod(s) spececiffy *tosure Removal Other �' < <br /> F,rm,t,j age, -c )Recent l<tcn )KOld(>I yr) pUnkm+wn <br /> P.t mated extent QLaeahzcd tank QLucalized piping CLucaimcd Dispenser -Large ihemnd cscavamd arcar 00tf-stip <br /> Pro d,�tyy rcl,ft md Guuline .Dmsd <br /> OM) Information provided for this study does not supersede standard reporting requirements. <br />