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L' Current UST Site Survey Form ,.W <br /> California State Water Resources Control Board <br /> Agency Information Impecuir•. l Agency: _ l7�te:.s <br /> Reason for.ins on: emoval QRcpair ❑Release mvcsugation c3 •umpliance inspection.. <br /> 3Other <br /> Site Information Site cmc: <br /> Address: <br /> Su=t Address - r—� city county _- <br /> ilitvnne QRetailGasolineOutlet ` ptha <br /> System Informadm ,�..-< .-._._;,,•: - <br /> IiiOk Material: 8arteSteel ❑Mfr.C.P. C31tetrofitC.P. pl.ined+C.P.: QClad C3Fiberglast OOtber <br /> Walls:+tSmglewall,<,.,❑Double Wall . _ " ...... <br /> Product:^ 00"Qline eset i Y <br /> Age: ❑<sn ❑S-I Q11-iSyr [Syr .�; •. ... <br /> Upgrade: ❑Spin QOverfill 0 Striker PlatePiRing <br /> Material:. ,&are steel A Qc3. QRigid fiberglass ❑Flexible <br /> Waft bbSingle 4 ODouble <br /> Age. Q<.SyrQS-lOyr DI1-ISyr iSyr <br /> ConnLhw COt`i....._. :❑Dispenser .-. (3Turbine <br /> puff.ping:.. ❑Ptemm QConventiomal Suction Safe suction !''❑Gtaviry <br /> Leak Detection.- <br /> M • <br /> at tmie tete=identified or at cloiftm telea= '- - - '•' •;,, tr <br /> vtIR S &qm sercontainn—tLD' QSIR(Brand/Model <br /> ❑iT(Brand/Modei'< �t } QPT(Stand/Model <br /> ❑tNT(Brand/Modd ). QATG (Brand/Mode! -)... <br /> ❑GW(Brand/Model t ❑Vadose(Brand/Model' <br /> :- ❑Meeh Ern ,...rs }.:.r• OElect.LLD(Brand/Mode! ::r }-: �•.:`" z: - <br /> (Braod1Model': <br /> East TIS► P aFut; Qtnconclusive Date: " <br /> jiSLPT' ❑Passtu.N"' x OFarl':' ❑Inconclusive '"• Date T-? Ttrwt ?w•tE <br /> '-.r:' r •its•th Y':"`:t J��•A�t�lig�s��.�✓cS�.t'"• i.��� a.;�t2: ..� '. ... :�f:•!ti•i"}� " .. _� 7 ..�Y ��sS'�i��M��-+• t � L�. <br /> i. L $I$?❑Pass "• ❑Fall.' plrieoncluave Date <br /> -1 - - 1. <br /> Release Informaboa v <br /> ❑tYa release suspected(skip terrninider of section) Date ofconfirmed release <br /> `''e � > died .•ti•.J�•`.tT••�..�. -. :?:�2:. ;.i'.��—� ..7- ��{''R''� � � <br /> ❑PkmcaI da=9 (3C0nwwm T QMechanicl failure-... ❑ Loose Fitting <br /> V-11 <br /> Faultg rnstallacon C1Structural Failure II Spill k Clnknovm 0Other3 t t <br /> $mss^f`- QTS' ❑Piping ispenser :' QSpill ❑Overfill "j !nknown QOther. <br /> ir <br /> v ClosurelRemoval Other <br /> How tdtentiBed. ❑LDtnethod(sy_ specify O x - <br /> Fsdn aced age teleae QRecatt(<iyrp QOId Nyr) lnkww-n <br /> F_timated extent-` CLoeali=d tank QLocalirsd piping localized Dispenser �L�rge(beyond exevated arra)• ❑OtF-aitr <br /> - f f <br /> a 3 <br /> Product released Gasoline• X <br /> _ :. <br />- _ <br /> (3/98) Information provided for this study does'not supersede standard repotting.requirements <br />