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sr <br /> Ito-6NDEROROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> t <br /> EMERGENCYSTATE TAN ID <br /> HAS STATE OFFICE OF EMERGENCY SERVICES <br /> F❑ YES N< NO REPORT BEEN FILED? 0 YES NO <br /> REPORT DATELOCAL CASE # REGIONAL B ARD CASE # US EPA 10 # - <br /> 'MOY Y .. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ClJREPRESENTING ❑ LOCALAGENCY ❑ OTHER COMPANY OR AGENCY NAMEILI <br /> �1 <br /> OOWNER/OPERATOR ❑ REGIONAL BOARtr •E� l�� rtA <br /> W <br /> ADDRESS �y �F ,/'7 �f�j <br /> tt 12000 :�-layfeda, d1� LLSG� 9 b�tC"i�.s v(1 Y .�0 TAITE / ! ZIPv� <br /> STREET <br /> I > NAME /�'��qq CONTACT <br /> PERSON PHONE <br /> y <br /> z� LV ❑ UNKNOWN <br /> O<Co' ,ry�/� 1.11 J� (,.J may/ !/� <br /> W-j JADDRES <br /> d-E�[.l� f `/0S'�T R E ET� de Lfi(.� <br /> CI Y STATE ZIP <br /> XJ-p/C�C ✓v . p 'I /R PFHyONE <br /> T le� ye Stl r• IFAACILITYNAME (IF APPLICABLE) OPERATOR <br /> /� »GV / - <br /> ADDRESS <br /> YO R&Tia' C1 CONTY ZIP?SJ <br /> J <br /> wCROSS STREET TYPE OF AREA COMMERCIAL ❑INDU TRIAL TYPE OF BUSINESS RETAIL FUEL STAT ION <br /> F <br /> N /.r�, ❑RESIDENTIAL ❑RURAL ❑OTHER ❑UNKNOWN ❑OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT FERSON PHONE <br /> O <br /> z /I <br /> zw REGIONAL H D - <br /> wU <br /> �z ( } I <br /> ww <br /> J O ITSCO <br /> ad <br /> w CAS # (ATTACH EXTRA SHEET IF NCEDED) NAME QUANTITY <br /> �� LOST (GALLONS) <br /> Q j (1) I Q.. / /t'� Tr ''���UNKNOW <br /> �-J <br /> NO121 �A.Y U1yfT,��.J�/�. IU/N,KNOW y <br /> DATE DISCOVERED +IT' HOW DISCOVERED ❑ INVE TORY CONTROTANK L <br /> ❑ SUBSURFACE MONITORING L/iA,-/-,-r/"- '/7 <br /> yr M 7 M , &b �Y / Y 0 ROUTINE MONITORING ❑ REMOVAL u NUISANCE CON DiT10N4 OTHER: d / U 1 J// <br /> Y �. <br /> ww D,/A�TE;OISCHARGE•BEGAN - METHOD USED TO STOP bISCHARGE (CHECK ALL THAT APPLY) <br /> Ow UI,q "�`µ iD &I �Y��Y.I - - ❑, UNKNOWN ❑ REMOVECONTENTS - ❑ REPLACE TANK ❑CLOSE TANK <br /> U <br /> �m HAS DISCHARGE BEEN STOPPED? /� (/� [�y� - ��REPAIR TANK REPAIR PIPING ❑CHANG/E PROCEDURES <br /> a ou <br /> YES NO IF YES, DATE "M NI �D `D "Y Y DgOTHER - �� � �+°( T-� Z-3 L J <br /> SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY GAL CAUSES) <br /> Ld f° ❑TANK LEAK ❑ UNKNOWN I 1 { ❑OVERFILL ❑CORROSION <br /> D AGE W YRS. ❑ UNKNOWN <br /> L) MATERIAL �RUP7URE/ AILURE ��SPILL <br /> w PIPING LEAK <br /> U �STEEL ❑ IBERGLA55 <br /> ❑OT}iER (SPECIFY) ❑OTHER ❑UNKNOWN ❑OTHER <br /> RESOURCES AFFECTEDWATER SUPPLIES AFFECTED THREAT- _ <br /> 4 5F <br /> YES NO THREATENED UNKNOWN YES IN�O ENED KNOWN WELLS <br /> F AIR (VAPOR) E3 � WATER Cl I_� PUBLIC DRINKING ElI_-.�-� ❑ <br /> wSOIL (VADOSE ZONE) ❑ El PRIVATE DRINKING <br /> L ' GROUNDWATER ❑ 0 ❑ WATER ' ❑ <br /> SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ INDUSTRIAL ❑ ❑ -❑ <br /> Us BUILDING OR UTILITY VAULT ❑ ❑ ❑ AGRICULTURAL ❑ ❑ 0 <br /> 0 OTHER (SPECIFY) CI Li ❑ ❑ OTHER(SPECIFY) ❑ ❑ ❑ 0 <br /> w <br /> w GROUNDWATER BASIN NAME <br /> s <br /> UNKNOWN <br /> COMMENTS: �y <br /> z <br /> w <br /> O <br /> U - <br /> 7 COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP ORK OR PLANNING HAS STARTED HSC 05 (10/85) <br /> �/ <br />