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UNDERGROUND STORAGE Ta UNAUTHORIZED RELEASE (LEAK)/GuNTAMINATION SITE REPORT <br /> EMERGENCY❑ <br /> YES [�rSTATE TANK ID <br /> HAS STATE OFFICE OF EMERGENCY SERVICES No REPORT BEEN FILED? ❑ YES ❑ NO <br /> CAD 1918 IL 14 16 L14_ 0 2 <br /> B <br /> REPORT DATE LOCAL CASE # REGIONAL BOARD CASE # US EPA ID # <br /> IMI I MI 06ISDIy y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> mllhirgeCtJtJVVr' +(&q- 21/1 E <br /> O REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPANY OR AGENCY N <br /> W <br /> ¢O �OWNER/OPERATOR �J/�c�/ ❑ REGIONAL BOARD (/T <br /> ADORES ' �ST EET <br /> ,aEasa✓ 64 9�s64 <br /> !/tv/' <br /> CITY STATE ZIP <br /> NAME CONTACT PERSON ONE <br /> 0 ❑ UNKNOWN LT Zi VW(�/� ( SFil 63•?�! 7 / <br /> Mm�n W ADORE {/.�]�/]/.r/ qw <br /> / °• O (KIT CITY C/9- ZIP CITY STATE ZIP <br /> FACILITY NAME (IF APPLICABLE( OPERATOR PHONE <br /> s - LE aoi, fy".p� L B 4 &rl-,r b r QVI <br /> ADDRESS <br /> 5 G/6REEO;eWrdi t14 ;rA4C7' $,��J04 011/4/ 953'!6 <br /> CITY COUNTY ZIP <br /> f CROSS STREET TYPE OF AREA COMMERCIAL O INDUSTRIAL TYPE OF BUSINESS E] RETAiL FUEL STATION <br /> Buthman W,44CESIDENTIAL ❑RURAL ❑OTHER ❑UNKNOWN ❑OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> FW REGIONAL OARD okl �• °TF_ �� �� <br /> WU <br /> Iw <br /> LL< TSCO <br /> I <br /> WO CAS x (ATTACH EXTRA SHEET IF NEEDED) NAME /' ��r/QUANTITY LOST (GALLONS) <br /> Fj 11I UAIL4A/.2012 V,4s01/J A1C` / Ql✓.✓ —EtrU'NKNOW <br /> mO <br /> M> <br /> E <br /> O <br /> H- (2) ❑UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> M M D V NUISANCE CON DI TION?y ❑ ROUTINE MONITORING REMOVAL <br /> TANK <br /> pz r�ST HER: <br /> >Z DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> U� D 'YJ V 'UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK Q'LLOSE TANK <br /> OQ HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑REPAIR PIPING OCHANGE PROCEDURES <br /> ES NO IF YES, DATE I M $ryjKy ❑OTHER Cal_ <br /> W SOU�RCE(S)OF DISCHARGE TANKS ONLYICAPACITY GAL CAUSEISI <br /> �^ R '1ANK LEAK ❑ UNKNOWN ❑OVERFILL COR 051 C <br /> O 'n o q <br /> V AGE II�-U7-� YRS. ❑ UNKNOWN L% f' <br /> V E]PIPING LEAK MATERIAL ❑RUPTURE/FAI L61%-C:j SPILL �~ <br /> STEEL FIBERGLASS L1 D l.- <br /> O 0; h { <br /> ON ❑OTHER (SPECIFY) ❑OTHER Z;.1TgiSNOWN ❑cJ9j�R .�3! <br /> \ RESOURCES AFFECTED yEs NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED <br /> W I-y YES NO ISO OW� LLS <br /> F <br /> AIR (VAPOR) ❑ ❑ ❑ E— PUBLIC DRINKING <br /> ❑ ❑ 1}L�... I`.Y"� <br /> W SOIL (VADOSE ZONE) ❑ ❑ E, ry WATER •SCS. LJ <br /> W GROUNDWATER 11 fIJL PRIVATE DRINKING ❑ ❑ C <br /> tY ❑ ❑ CJ L-'J WATER <br /> WR SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ �/ INDUSTRIAL ❑ O ❑ �� <br /> M, BUILDING OR UTILITY VAULT El E] O [P AGRICULTURAL EJ F-1 ❑ L7�/ <br /> vOi OTHER (SPECIFY) EJ ❑ ❑ ❑ OTHER(SPECIFY) ❑ ❑ ❑ ❑ <br /> W <br /> C GROUNDWATER BASIN NAME <br /> NKNOWN <br /> COMMENTS: <br /> F The Southland Corporation is in the process of attempting to find an environmental <br /> w company who can quickly respond to this matter. Will advise by letter once one has <br /> i been secured. <br /> O <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED HSC 05 (10/85) <br />