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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/C NTAMIN&TION SITE,REPOR. <br /> EMERGENCY STATE TANK IDD <br /> HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ VES ❑ NO REPORT BEEN FILED? ❑ YES ❑ IN v � <br /> REPORT DATE LOOAL CASE # REGIONAL BOARD CASED S E <br /> 0 0 5D S ;- Prrq 7) <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE MENTAL I�EALTH <br /> -3 r <br /> O REPRESENTING ❑ LOCAL AGEN V OTHER COMPANY OR AGENCY NAME <br /> W T <br /> ❑ OWNER/OPERATOR ❑ REGIONAL BOARD ���i �' fA.sso"'<tc'5 <br /> w ADDRESS <br /> a fpsUr���err,�Y � �dLt 3tj Qn- C� gq}o <br /> STREET CITY STATE ZIP <br /> lY NAME CONTACT PERSON PHONE <br /> _F cyy Y�^ ri w. �J(,. �l <br /> Z4 Sw I..JG SVO.t QJ� il'�C.. ❑ UNKNOWN -7S'�k� ... I vY\o (V� ) �70r— �`(Q <br /> a ADOR¢m ` N ` J �1 <br /> J4C �Q� <br /> STRET T� <br /> ZFACILITY NAME OF APPLICABLE) OPERATOR PHONE <br /> � <br /> O ( J <br /> G ADDRE S <br /> U <br /> O <br /> J STREET CITY COUNTY ZIP <br /> w CROSS STREET TYPE OF AREA ❑ COMMERCIAL INDUSTRIAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> z IV <br /> m RESIDENTIAL ❑RURAL ❑OTHER F]UNKNOWN OTHERI!!L" <br /> LOCAL AGENCY q AGENCY NAME <br /> CONTACT PERSON PHONE <br /> �_ So.•. `S�o4 V' r 6-O�-G C�Qi.CT� O Sl L.4Vr^ �'r✓��U- (�Q J 1(1-�' � �� <br /> FW <br /> REGIONAL BOARD <br /> OA <br /> ww <br /> da TSCD <br /> s <br /> W CAS # (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> Un I <br /> 6> (1) Ld UNKNOW <br /> 'J <br /> .0 <br /> m> <br /> =- (Z) ----47:] UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING�, .t}, <br /> jF tlM ,M qO ay �V ❑ ROUTINE MONITORING ❑ REMOVAL El NUITANK SANCE CONDITION'S !YI OTHER: )"f` IvvA <br /> z l � <br /> Z DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> >F <br /> OUF M M O D Y Y UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑CLOSE TANK <br /> p0 <br /> 6 HAS DISCHARGE BEEN STOPPED? L]REPAIR TANK ❑REPAIR PIPING [_]CHANGE PROCEDURES <br /> IF-JYES NO IF YES, DATE I MI MI DI D V V ❑OTHER <br /> w SOURCES) OF DISCHARGE TANKS ONLY/CAPACITY 1_(j GAL CAUSES) <br /> '^ TANK LEAK ❑ UNKNOWN `� ❑OVERFILL ❑CORROSION <br /> Q AGE W YRS. ❑ UNKNOWN <br /> U <br /> U ❑PIPING LEAK MATERIAL 'SAI ❑RUPTURE/FAILURE EISPILL <br /> m EDSTEELFIBERGLASS <br /> ON ❑OTHER (SPECIFY) ❑OTHER " UNKNOWN ❑OTHER <br /> RESOURCES AFFECTED HREAT­ UN- <br /> YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED NO ENED KNOWN WELLS <br /> O F AIR (VAPOR) ❑ I]! ❑ _� PUBLIC DRINKING ❑ ❑ ❑ <br /> W WATER <br /> SOIL (VADOSE ZONE) l� -- <br /> 1L GROUNDWATER ❑ �� ❑ WATER DRINKING ❑ Ipl 11 ❑ <br /> <X <br /> W SURFACE WATER OR STORM DRAIN ❑ I ❑ Im <br /> INDUSTRIAL ❑ ❑ ❑ <br /> U,- BUILDING OR UTILITY VAULT ❑ ❑ ❑ AGRICULTURAL ❑ ❑ ❑ <br /> �a OTHER (SPECIFY) �� w❑J ❑ ❑ OTHERISPECIFY) ❑ ❑ ❑ <br /> W <br /> W ' <br /> 0: GROUN WATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS:COMMENTS: <br /> z <br /> z <br /> w <br /> E <br /> s <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 />