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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES STATE TANK ID -+ <br /> LJ YES >< NO REPORT BEEN FILED? ❑ <br /> YES � NO <br /> REPORT DATE LOCAL CASE # REGIONAL BOARD CASE # US EPA ID # <br /> DM 7 M 2-o I [)I `�Q Y -7:y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Hav7K Sheefi-z ( ,{l5) 941- 13o4 I N��-4- gAgst� /Ak_C� <br /> o <br /> ILI 17 REPRESENTING L_j LOCAL AGENCY ❑ OTHER COMPANY OR AGENCY NAME A - <br /> 0: >< OWNER/OPERATOR ❑ REGIONAL BOARD Ake-- Pe4-ro1eam P--oduc.t:s C8e"pan <br /> (I- <br /> ADDRESS <br /> Wood Cd, pttaSanlv-m_ /4a 171/5-66 <br /> D: <br /> STREET _ CITY STATE ZIP <br /> I > NAME <br /> n /�/� CONTACT <br /> �/PERSON PHONE <br /> Z¢ jhC-D r C� Yf7 PI�Od• L:] UNKNOWN Han, She-e-f e .571 - 2 4ol <br /> WJ ADDRESS 2 V U U /T r Q h"Z•e GL.� C.a-C� CGC r V/Q�Q/�f �(; Imo- // (GCT"'e-o l�I-1 /T T�/3 <br /> m m STREET J CITY STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> Apco '5 zzwc-m (0100 lkicit ard- fi3 )kide..s 229 ) 83, - 7777 <br /> ~ ADDRESS <br /> 257'75- ou+h PaWe 6a Pass 2d. , 'Trcu,�f_ 5an -Jo a, vin. <br /> O STREET CITY COUNTY ZIP <br /> J <br /> F <br /> CROSS STREET Q TYPE OF AREA COMMERCfAL ❑INDUSTRIAL TYPE OF BUSINESS J�RETAIL FUEL STATION <br /> 141'9yrWav �c/ IE]RESIDENTIAL><RURAL [--]OTHER F UNKNOWN DOTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Z Sa44,rirc ( a"n Lo e_&i I-ka#-A- leis, Doug, Ltll`15d�- (^90,7 ) 4,L P o- (,7$/ <br /> Zw REGIONAL BOARD <br /> W U <br /> f Z ( ) <br /> W W <br /> a a TSCD <br /> W CAS d (ATTACH EXTRA SHEET iF NEEDED) <br /> 1'7-IE <br /> NAMEQUANTITY LOST (GALLONS) <br /> / 0. UNKNOWN NOWQj (1) � A -S '1 E / L furA- � Uurl✓ Qi <br /> wo <br /> rerrl o r <br /> m_> <br /> m- (2) <br /> n UNKNOW <br /> DATE <br /> DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> TANK <br /> }H OMI4M I , /D p.oY 7 Y [:jROUTINE MONITORING REMOVAL NUISANCE CONDITION'i r I OTHER: <br /> T Z <br /> WW DATE DISCHARGE BEGAN�J METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> Uw Omi4mI � D / DI VYI / YI ❑ UNKNOWN >S REMOVE CONTENTS REPLACE TANK ❑CLOSE TANK <br /> om HAS DISCHARGE BEEN STOPPED? ��JJ r �y REPAIR TANK ❑REPAIR PIPING ❑CHANGE PROCEDURES <br /> ¢ YES E] NO IF YES, DATE I OM TM D /y Q�D OY / Y OTHER r__e 'hQV0_ -Aahl— <br /> W SOURCES) OF DISCHARGE TANKS ONLY/CAPACITY 550 GAL CAUSE(S) <br /> WTANK LEAK ❑ UNKNOWN I I ' ❑OVERFILL ><CORROSION <br /> ¢ AGE W YRS. K UNKNOWN <br /> U <br /> III PIPING LEAK MATERIAL ❑RUPTURE/FAILURE C5<SPILL <br /> U STEEL ❑ FIBERGLASS <br /> T K <br /> I❑OTHER (SPECIFY) -]OTHER ❑UNKNOWN [:]OTHER <br /> RESOURCES AFFECTED WATER SUPPLI ES AFFECTED TH - - <br /> \O YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS <br /> H AIR (VAPOR) El ®. 1:1C] PUBLIC DRINKING ❑ ❑ ❑ <br /> W SOIL (VADOSE ZONE) <br /> U WATER <br /> x D El El <br /> L Y GROUNDWATER ❑ ❑ ❑ PRIVATE DRINKING ❑ ® ❑ ID <br /> L WATER <br /> W SURFACE WATER OR STORM DRAIN ❑ 1:1 El INDUSTRIAL ❑ ❑ ❑ <br /> RQ BUILDING OR UTILITY VAULT ❑ X ❑ ❑ AGRICULTURAL ❑ ❑ <br /> = ID El <br /> O OTHER (SPECIFY) �� ❑ ❑ ❑ OTHER(SPECIFY) ❑ ❑ <br /> w <br /> W <br /> S - GROUNDWATER BASIN NAME <br /> S6Z"-l10CC /K• ❑UNKNOWN <br /> COMMENTS: ��i�VL�L�/ •o`vG�f C.(i'c�� T�'�/�Ci�/I�XJ <br /> LLI <br /> s <br /> o c <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK PR PLANNING- Hsc 05 (10/95) <br /> e � <br />