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UNDERGROUND STORAGE TAN114-ONAUTHORIZED RELEASE (LEAK)/LLfTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES STATE TANK ID = j <br /> 1 <br /> IYES NO REPORT BEEN FILED? [:] YES O NO <br /> REPORT DATE LOCAL CASE F REGIONAL BOARD CASE A US EPA IO A <br /> Qa 3M0D ) o �r `a r <br /> NAME OF INDIVIDUAL FILING REPORT PHONE j] _$LS_ 4444 SIGNATURE <br /> m 1AA t 11F- SHS rz ( �) rock 4$t -1304 �0 Mi�'� <br /> W REPRESENTING Q LOCAL AGENCY O OTHER COMPANY OR AGENCY NAME <br /> LOWNER/OPERATOR O REGIONAL BOARD PE-VgoL4E.I," <br /> m ADDRESS <br /> COST c>PFsCe T �oX sg(1 �kaJ 1,4kreo CA 944°3 <br /> CITY STATE ZIP <br /> it NAME !�f-J CONTACT PERSON PHONE-�r,Aw�, <br /> �¢ 1 to)( <br /> � CI) C UNKNOWN TF <br /> ADD <br /> ttm <br /> 'Po-z- pFF1RE TP»X 5811, SA-r1 c1i'Y � ATE <br /> FACILITY NAME (IF APPLICABLE) PERATOR PHONE <br /> Z O <br /> FACGL(T-I * 4493 30*+r) )44$ - 0036 <br /> ADDRESS <br /> Q �fj ry/ GE NTE fit . �TocKTon1 .1 !0 6?Lt(w1 X5202 <br /> O '"`�� STREET CITY COUa Y ZIP <br /> J <br /> W CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL j!SRETAIL FUEL STATION <br /> H TYPE OF BUSINESS <br /> 44"tjr I[:JRESIDENTIAL ORURAL OTHER UNKNOWN QOTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> do . SPA0,44 L-OcAr %cr. L-o(Lt Cor(,LJ,,LeIr ( )466- 10-t8( <br /> iw <br /> REGIONAL BOARD <br /> w w c04rRA-- VALJ E`f Fli, �-4 cs w-f- BuCaGS (A i6 )36l - 574o <br /> 4 TSCO <br /> F <br /> ( ) <br /> wCAS A (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> QD //per <br /> c> 17I L1n.lE Cexc�ALe1R. --DTUNKNOWIS <br /> FJ <br /> .0 <br /> 7_ (Z) _�UNKNOW <br /> DATE DISCOVEREDA� � HOW DISCOVERED Q INVENTORY CONTROLr-L,, -� SUBSURFACE MONITORING TAT.1�C- I"TEGFHF-/ <br /> �F �M � D D 8Y l V ❑ ROUTINE MONITORING ❑ TANK ED u NUISANCE CONDITIONS OTHER: 'WEE T&U <br /> ,N- <br /> ,W DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> OF (M ZM I D (OD1 JqYj 7 Y O UNKNOWN Q REMOVE CONTENTS Q REPLACE TANK O CLOSE TANK <br /> Om HAS DISCHARGE BEEN STOPPED? �f �' + /_ Q /j Lj PAIR TANK REPAIR PIPING CHANGE PROCEDURES <br /> ¢ VES NO IF YES, DATE j M SWI 1 D &DI 9Y l Y tLJ"'HER �(�aNT1�lA� �� 1�5� <br /> W SOURCES) OF DISCHARGE TANKS ONLY/CAPACITY ,5�Q%2 GAL CAUSE(S) <br /> TANK LEAK UNKNOWN OOVERFILL E]CORROSION <br /> ¢ AGE LJJ YRS. [DUNKNOWN <br /> UPING LEAK MATERIAL RUPTURE/FAILURE E]SPILL <br /> ¢ QSTEEL O2 F/IBERGLASS <br /> H r-JOTHEP (SPECIFY) a OTHER UNKNOWN O OTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED <br /> YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS <br /> f AIR (VAPOR) O U L PUBLIC DRINKING I-1 <br /> W SOIL (VADOSE ZONE) �Ey/ WATER <br /> 1, O O CJ PRIVATE DRINKING <br /> <Y GROUNDWATER O 0 �r�' ��.( WATER <br /> W R SURFACE WATER OR STORM DRAIN D O u l.Y_I O O <br /> yly INDUSTRIAL <br /> U1- BUILDING OR UTILITY VAULT O O O AGRICULTURAL 0 O El d <br /> DO` OTHER (SPECIFY) 13 Q O Q OTHER(SPECIFY) 0 0 O <br /> W <br /> ¢ GROUNDWATER BASIN NAME <br /> NKNOWN <br /> COMMENTS: <br /> n <br /> r <br /> z <br /> w <br /> i <br /> z <br /> O <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED MIC ON IIo/eel <br />