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UNDERGROUND STORAGE TAWIC UNAUTHORIZED RELEASE (LEAK)/MNTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES STATE TANK ID h <br /> YES 1�4_NO REPORT BEEN FILED? D ��} <br /> YES Ili- 11 <br /> PORT DATE '?',17 <br /> n^` LOCAL CASE # REGIONAL BOARD CASE # US EPA ID # <br /> MI oM 'ro �D "Y 7 Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> C. ihK �he,�f (4/S) 4-e - l 3o4 <br /> W REPRESENTING LOCAL AGENCY OTHER COMPANY OR AGENCY NAME / <br /> O OWNER/OPERATOR REGIONAL BOARD �' �v rn R.'-vc�f� c-l-'-745 <br /> /� �j1 <br /> a ADDRESS '`o�l.9 �w�IK/��( � I 45(p 10 <br /> W <br /> Q <br /> STREET _ CITY STATE ZIP <br /> I > NAAMMEf��/ �jj CON�TAC'TnP,[E�RSON J/J /JQ PHONE <br /> z0< / 1 r� UNKNOWN <br /> o W ADDRESS <br /> W m Y o oo STREET�'1 C(�-t e- Gar c !aa leu I a/j- Su A- 7'y q CITY SL°f}E X1 0 3 <br /> ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> "Ceo �5g�tc i�x /s2�1�X3.3/��� p�/� byl�. 5 4w/a Ip a r of ( 2.0/y) 7g -5-55 z <br /> ¢ ADDRESS <br /> 2�D (J �l(/i•////l i / v a,.� J�� s�lJ/�- 'saki - <br /> U J <br /> O STREET CITY COUNTY I ZIP <br /> J <br /> F CROSS STREET TYPE OF AREA COMMERCIAL �INDUSTRIAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> Plyrnov� !C'd ��RESIDENTIAL ��RURAL OTHER [-JUNKNOWN OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zN Barr`-Jo a lYz h LoCrc.Q Laurie �//cam. clay ) 4& -&79 <br /> ~W REGIONAL BOARD <br /> Z- <br /> U <br /> W <br /> �Z ( ) <br /> W IJ <br /> a Q TSCD <br /> CAS # (ATTACH EXTRA SHEET IF NEEDED)r NAME QUANTITY LOST (GALLONS) <br /> ¢> (1) wV 0J� ,UNKNOW <br /> FJ <br /> 00 <br /> C3 7 I I Jl UNKNOW <br /> n- (2) <br /> DATE/ �DISCOVEREDQ' HOW DISCOVERED a 'NVENTORY CONTROLL, 0 SUBSURFACE MONITORING <br /> TANK <br /> jH 0MDM D OD VY / Y U ROUTINE MONITORING {IIIREMOVAL I—I NUISANCE CONDITIONS �_� OTHER: <br /> Z <br /> f DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE��`�CK AAJLL THAT APPLY) <br /> vle <br /> OF M' M DI D YI Y UNKNOWN Rl REMOVE CONTENTS �FiE@LA6E TANK nCLOSE TANK <br /> U <br /> E5HAS DISCHARGE BEEN STOPPED? `_REPAIR TANK REPAIR PIPING [::JCHANGE PROCEDURES <br /> ¢ p. �J p. �J <br /> YES NO IF YES, DATE V/�M O M ^D 0 D OY /Y C]OTHER <br /> W SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY 55� GAL CAUSE(S) <br /> ( TANK LEAK UNKNOWN OVERFILL CORROSION <br /> ¢ AGE YRS. K UNKNOWN <br /> W L�PIPING LEAK MATERIAL RUPTURE/FAILURE [:]SPILL <br /> U STEEL F_� FIBERGLASS <br /> Ir AZ <br /> IF OTHER (SPECIFY) OTHER O UNKNOWN [::]OTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT­ <br /> YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS <br /> I-- AIR (VAPOR) O El PUBLIC DRINKING u 1--] [_-I R <br /> W SOIL (VADOSE ZONE) El <br /> U WATER <br /> El <br /> W �] PRIVATE DRINKING O f� <br /> U. <br /> GROUNDWATER <br /> Elr-� EJ XWATER <br /> El L'J <br /> W SURFACE WATER OR STORM DRAIN E] El p INDUSTRIAL I E] El K <br /> Q{- BUILDING OR UTILITY VAULT L� l El O RL AGRICULTURALLI F7 El XL <br /> 0¢ OTHER (SPECIFY) 1-1 C7 a 1:1OTHER(SPECIFY) a <br /> W <br /> 5 GROUNDWATER BASIN NAME <br /> Saki--,Joa 0 UNKNOWN <br /> COMMENTS: <br /> N <br /> F <br /> Z <br /> W <br /> O <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRS .ING REPORT IF ANY CLEANUP WORK OR PLANN` HAS STARTED HSC OS (10/85) <br /> i <br />