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r <br /> LE7 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMI T�QK-SI,T,E,8.gPPRT, <br /> RGE NC r - <br /> $7nTE TANK Ib <br /> YES _ NO HAS STATE OFFICE OF EMERGENCY SERVICES . I = <br /> REPORT BEEN FILED' y YES NO 1�1 oI ® r;OD , <br /> /,31� <br /> EPORT DATE LOCAL CASE a LS �( �a <br /> E REGIONAL BOARD CASE T15 EPAlD•Y <br /> I Q a Q ,�. r ' <br /> M M I D D! "Y 1 , Y 1 <br /> NAME OF INDIVIDUAL FILENG REPORT L-_TNE SIGNATURE <br /> �' rtir;^.JAL EA LTH <br /> m _� w c r Lam,� L) 5 ) (et-lI/`" 31 <br /> O REPRESENTING <br /> F FOCAL AGEN Y OTHER MPANY OR AGENCY' NAME <br /> OWNER/OPERATOR `I REGIONAL BOARDt <br /> O ` v -s <br /> � ADDRESS C S � Lam{ � Com} <br /> Is, ti- <br /> I <br /> I NAME <br /> STREET CITY STATE 21P <br /> > <br /> -r CONTACT PERSON PHONEO <br /> I <br /> C� <br /> `< < ��..� ��? —L ,,c� J-UNKNOWN <br /> may, ADDRESS nI i CA <br /> x <br /> CITY STATE Zip 1 <br /> FACILITY NAME (3F APPLICABLE) OPERATOR <br /> Z PHONE <br /> a AODRE S ( , <br /> U <br /> O <br /> J STREET CITY COUNTY ZIP <br /> LJ <br /> +- <br /> CROSSSTREET TYPE OF AREA COMMERCIAL lNDU5TRIAL TYPE OF BUSINESS ,-,J RETAi� FUEL STAT ICti <br /> I� I RESIDENTIAL :]RURAL 'OTHER �['{ � <br /> r IUNKNOVIN I kOTHFR <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z r <br /> Z S�.", '-S'cst, L� 1r. �� `\CJS\l�- b�1L L[.Vr 1 �G�✓1�� (�� } I6L - 6,4J <br /> F N <br /> z w REGIONAL BOA (tel <br /> wv � SJL It I " C�tlon ,,C• <br /> q TSCO I <br /> ( } f <br /> CAS a (ATTACH EXTRA SHEETIF NCEDED) NAME <br /> 11zt - J QUANTITY LOS' (GALLONS) <br /> Ste} .—V'1 UNKNOW <br /> O YY I <br /> m_> <br /> N- (2) I I I I <br /> UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL L SUBSURFACE MONITORING <br /> L <br /> ��/ <br /> }�- MI IMI � �D r �Y ROUTINE MONITORING TANK REMOVAL L 2 NUISANCE CONQITfON, ] OTHER i�-+tiN f"�},iYw <br /> C z /1 <br /> >2 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL -HAT APPLY) <br /> wM' D' D' UNWN T <br /> OF MI YI Y I REMOVE CONTENTS -I REPLACE TANK <br /> 0< KNON <br /> CLOSE TAK 1 <br /> n HAS DISCHARGE BEEN STOPPED L REPAIR TANK REPAIR PIPING J ,_CHANGE PROCEDURES <br /> ^'YES NO IF YES DATE Ml MI D DI yi y E OTHER <br /> W .S�OF.URCEISI OF DISCHARGE TANKS ONLY/CAPACITY l �,UdO GAL CAUSE(S) <br /> STANK LEAK UNKNOWN �OVERPILL CCRROSION <br /> 7 j� <br /> c AGE 1J,4i YRS a UNKNOWN <br /> v <br /> W i PIPING LEAK <br /> MATERIAL <br /> C r~i STEEL Iffy ` r <br /> 3 RUPTURE/FAILURE lSPILL <br /> D J L� FIBERGLASS �.� <br /> DTH£= ISPECFFvI `07 HER IV I UNKNOWN = OTHER <br /> RESOJRCES AFFECTED YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED <br /> w <br /> AIR [VAPOR! YES NO CNCq' KNOWN WELLS <br /> u r 1-� WATER PRINKING D W [--3f - 1 <br /> C� .` <br /> u SOIL SVAbgSE ZONE( CI 7y <br /> L ,a}, PRIVATE DRINKING 1 <br /> `Y GROUNDWATER LI WATER <br /> N`n SURFACE <br /> Jr WATER OR STORM DRAIN <br /> .J INDUSTRIAL <br /> BUILDING OR UTILITY VAULT <br /> ^-L1 <br /> +-� <br /> AGRICULTURAL <br /> OTHER (SPECIFY( <br /> C OTHER{SPECIFYI <br /> GROUNDWATER BASIN NAME <br /> �UNKNOWN <br /> OvVENTS <br /> f r <br /> 7 <br /> �..0 Pl_��F 44'1 4--E.-t, .. cL� iic -cr rVt --r -- � ♦ .. - - -.- --- _ _ - .. <br />