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Current UST Site Survey Form <br />California State Water Resources Control Board <br />Srncv Information Inauccmc Agca:y <br />�crtarval <br />00ther <br />OKcgj,r Q Rclesse mvesnonon Qd'rrryrhmsx ntspeeWud <br />//PryO—,F 1 Isl _ i I a � <br />IQ <br />ti to Inlormanoe <br />1 N•7 S • ��r�is9q�. <br />S t"a G K Fo->ti S« Pt n Q,..� <br />Street Address <br />Ciry Cwmry <br />F+ ice: tq l Gsscline Ouch ❑other <br />1"� <br />Zjajt Ma¢nal: Sted <br />❑Mfr. C3. <br />QRetmtit C-°- QLined-C.?. ❑Cad 0,Fhesglsss QOtber <br />Wa1Lt vrall <br />QOouble.1111 <br />���$ingle <br />Produce )<Guoline <br />�Diae) <br />..Age <br />Q<syr <br />Q5_loyr <br />C311-15yr tit>15yr <br />upgmde: ❑Spin Qovernn 0 Striker Flue <br />pining <br />Material: >(w,.. swel QC,P. ❑Rigid fiberglass ❑Flexible <br />Walls: Xingle ❑Double <br />Age; Q<Syr QS-10yr C311-15yr Xi Syr <br />u <br />Cone rt QDispensc QTurhme QNope <br />Fungmg: QPetsnue QConvmdonsl Suction QSate suction QGdanry <br />T.P+k Detection <br />Mcd <br />n dt , used t mine rel -ed [ d I = ustin 1 ) (s 1 R) <br />❑MIR Q Sutrp dispenser mpoopmen[ Lo QSIR(BrandModel —_`? <br />�Dri zor• <br />Qtr Br11ncVModd) OFT (BrmdMedel G t <br />0[NT BtondModcl ) ❑ATG (BnndtMode( <br />QGW(BramiNodel ) Qvadose(BrmddModel ) <br />QMeclL.LLD (BrAWMOM ) ❑Elam LLD (BrmdlModcl ) <br />I an= Pus QPoii Q)m sissio ive Date <br />L12.Q FL2 <br />ast22�' Qrroil pmeardusive Due: <br />Iq <br />f A<t c)R?`Q_pass QFaiI Qb¢rcondusi"s <br />R 1 ere it r nformadon <br />ON, release suspected (skip a a oder of secvpn) Dam of confirmed mleasc <br />cause. QP)tysical durage p omission QMeehmiel aloe a Loose Fltang CI Overfill <br />Qf-addry itaoBanon 0 Slnuaval Fiflu e a Spill )knkno-v Qodw <br />Sauces: ❑Tank 'Piping fDuowa QSpiu C ov`en'in C (:nmro n corner <br />tlow idem,111 l^ QLD mediod(s) soecify `� '$Closure R mp» al Qotha <br />Fstim_tal ave xle-.e`Q'Recem 1< Irn \/ 1W Ol yyrr)) QUnkknno. <br />I:1omsult ••<te*r••<te*r dl..ralisd tank 11l. liz d piping 1n Lu ZIiaed Dispero r _!merge Iheyr d eaeaeated v ) <br />Pmduct released /��l ,,� awlim '1 Dmsel <br />( 3/99) (nfomianon provided for this study does not supersede standard reporting rcquirements. <br />