Laserfiche WebLink
Current UST Site Survey Form <br /> Califomia State Water Resources Control Board <br /> ,4Pr•ncy Information Inspector - j� Agency: S� Dow: <br /> Reason ing en etion: Xemuval QRepair Q Release inmugauon Q('umplianee inspection <br /> QOther <br /> Site Information Sitcname r _S,$ ��a ` <br /> 7a d 3 c;Fi r✓ I}Jff f o�/� / S 4,vk J o a <br /> A Iy ISS:: County <br /> Street Address City tY - <br /> Facility nae: /Oeail Gasoline outlet Qothcr <br /> System Information <br /> y5ak Material: QBarc Stccl QMfr.C.P. QRetmfit C.P. QLined+C.P. lad QFiberglass QOther <br /> Walls:; QSingle wall Y.t louble wall <br /> Product: ❑Gasoline ❑Diesel <br /> Age: 0<5yr X5-IOyr _ C311-15yr 0>15yr <br /> Upgrade: ❑Spill ❑Overfill 0Striker Mate <br /> Pioina <br /> Material: QBam steel OC-P. <br /> Walls: <br /> fiberglass QFlezible <br /> Walls: QSingle sble <br /> paJ <br /> Age: 0<5yr .. _IO)T 0II-15yr -.0>15yr _ <br /> Containment: QDispenwr ❑Turbine -None <br /> Pumping: *`=-- ❑Conventional Suction ❑Safe suction ❑Gravity <br /> i eak Detention <br /> [h '( )used ill tirne mime identified-or at claem ifrro relea=se: <br /> ❑MIR Q Surrrp dispeaser containncat LD ❑SIR(Brand/Model 1 <br /> OTT(Brand/Model 1 QPT(Bnnd/Model 1 <br /> QINT(Brand/Mode1-1//1L&" Root 1 ❑ATG (Brand/Model ) . <br /> QGW(Brand/Model - 1 QVadose(Brand(Model 1 <br /> QMech.LLD(Brand(Model ) ❑Elect.LLD(Brand/Model 1 <br /> t s�:. Pass ❑Fail Qlnwndusive - Date: <br /> IastPT' i'au ❑Fail - Qlmonclusive Date: <br /> Last SIR? ❑Pass ❑Fail ❑Inconclusive Date <br /> R I acFormation �-_ JS'^(f'(p' 't. <br /> QNo release suspected(skip[ertninder of section) Dale of confirmed release <br /> Cause, .,. "❑Physical da onage <br /> _ QCormsion ❑Mechanical failure Q Loose Fitting Cl Overfill _ <br /> . „ ❑Faulty mstallatian Q Strumial Failure ❑ Spill w�Jnknown ❑Other <br /> Sotoe.., ❑Tank" bFiping ❑Dispenser Y:QSPill ❑Overfill )0 Unknown - ❑Other <br /> [low'dentifiedn QLD method(s) specify )XIosurelRemoval ❑other <br /> F=Cmated age rclea=S❑Recent(<Iyr) QOId(>l yr) 10Jnkknown <br /> F,(nFan+tent ❑Localized tank ❑Localized piping. ❑Localized Dispenser kge(beyond excavated arca) 0011'-site <br /> I'm 1 iry t rsl�+tied Gasoline Diesel <br /> (3/98) Information provided for this study does not supersede standard reporting requirements:, <br />