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Current UST Site Survev Form <br /> Califomia State Water Resources Control Board <br /> Agency [nformation b,vwti:ur _ Agrncy — u=te: — <br /> Re^<on fnr Inc ep etion: Kennrval QKepvr Q Kd�_se mv�sueluon Ql'umpbance mspecmm <br /> -.Otho <br /> FRS t' S `/ MA/0 <br /> S'te Information Siicaaes� _ <br /> S�-O C K+C'lw <br /> Sueet Add`ress3 City CountyF- llty, oC: p-mii Gssoline Dune[ Qothr. <br /> System Information <br /> yang Matenai: -.Bare Stccl awn C.P. QRemik C.P. -.Lined-C.P. L;Cad QFbergiass Ne. <br /> Walls: xmgiewall QDoubic.il l <br /> Produce Gasoline -.Diesel ` ' 6 <br /> Age: Q<Syr 05-10yr all-15yr "�>15yr tt4j-,— <br /> Upgrade: QSPIR QOVernll Q Spiker Plate <br /> Noon <br /> Normal: ate steel QC.P. - -.Rigid tibe:glass QF!ezih{< <br /> Walls: Ingle -.Double `l <br /> Age: ...///'''cl<Syr Q5-t0yr Q11-15yr 5yr <br /> Contammene �QDispenscr QTurbme �Qlone s' <br /> Pumping: �r'�n+te QConvenaonai Suction` -.Sate sewn QCm�iry <br /> i a^kms Damon /� <br /> Mvhg <br /> 's'tised,---trjcast,amnimd,or = <br /> QM1R Q Surap dlsperiser conuitunent tJ /APIR(Bnnamodei tit-5 �/sllT'�t/l1 <br /> QTT(BrandtModel QPT CB=d/Model E-?=Y e rte% <br /> Q[NT(BrandlModcl 1 -.ATG (Brand Mode! <br /> —GW(Brand/Model ) QVadose(BrandNiode! i <br /> QMech.LLD(Brand/Model 1 QE!ecr.LLD(Brand/Nlodei p 1 <br /> I alt= -.Pus -.Fail Q!nconclusive Dace: I Q — 7 <br /> LAU= c3Pass -.Fail Qlnconcimwe Date: <br /> 1 7 y <br /> ZLS R? -.Pus QFaii Qlncancluvve Date. )-i,— A <br /> Release Information <br /> QNa release suspected(ship rermtnder ai section) Dale of contirttrcd teiease <br /> QPhysiml damage -.Corrosion QMectimiml failure �jQ Loose Fitting ❑ Overfill <br /> QFauityinstallation ❑ Scucmmi Failure Q Sptil Iy t:nknown -.Other. <br /> S4LS[: -.Tank -.Piping -.Dispenser QSpi!1 ❑OvertiXL/ll oknavn -.Other <br /> How'dentifiM_^ QLDathod(s) specify losum Rcmovai —.Other <br /> F<t m^tea we _,QR¢cst(<1}n dOW(h lyg QCnkna.n <br /> 1:.am�yy"Ie'r QLacatrtN tank QLoalitedrpipmg QLpa1m:d Oispenscr Q;Large beyond csarated areal QOITsuc <br /> P^r ayl (lasulinc "Duel <br /> (3/98) (nformation provided for this study does not supersede standard repomng rrouirnments. <br />