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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/COiV7AM1NATI0N SITE REPORT <br /> ' STATE TANK ID a <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YESNO REPORT BEEN FILED? YES �NO y u 1 US EPA 1D # <br /> Lp^RL CASE #. REGIONAL BOARD CASE # - '' <br /> REPORT DATE ►�-j <br /> SIG RE <br /> M M NE <br /> NAME OF INDIVIDUAL FILING REPORT PHO ��� r 2�� D <br /> r 0-arl Sk.GtJ O� (415-) <br /> m ❑ COMPANY OR AGENCY NA <br /> I <br /> LOCAL AGENCY OTHER <br /> w REPRESENTING /S�) A ✓'f <br /> K OWNER/OPERATOR ❑ REGIONAL BOARD A/-(_//yL�/ CJ �Jam/ <br /> d ADDRESS F�G(,d T�f.�� W/�- /(Q.r / '�t'7� <br /> w 2�-p !} 1 aYd�(.2d ml STATE ZIP <br /> ¢ CITY ' <br /> STREET PHONE <br /> CONTACT PpERSON �y r/ / Q <br /> 2>- NAME f ' /if�f GfiY� ( 6 0 1 ) moi' ZZ-1 O <br /> �� UNKNOWN (20 . <br /> C.o-v C'. GI�s3 3 <br /> aIL <br /> W ADDRESS � '�5� �ll -fir CITY� � - STATE ZIP <br /> LU m STREET - - PHONE <br /> ICABLE) OPERATOR 7. ' ^ 2dy ) 333-- <br /> FACILITY NAME (IF APPL - � -1 V <br /> S.�/iCIL <br /> i ¢ ApDRE55 (�(�/{� Y�n�� COUNTYZIP <br /> O a6 1 {/L� l�-�/�T tom ' - CITY • i, <br /> y O STREET RETAIL FUEL STAT ION <br /> w TYPE OF AREA ..COMMERCIAL INDUSTRIAL TYPE OF BUSINESS <br /> F CROSS STREET - UNKNOYlN ❑OTHER <br /> 0 CJ RESIDENTIAL ❑RURAL Q�OTHER <br /> _ CONTACT PERSON � PHONE <br /> LOCAL AGENCY AGENCY NAME <br /> z `c. 1 oa ,nY�- t• h v h-rty can ,j ,tt r '�' <br /> W REGIONAL BOARD - ) <br /> Z- <br /> wU <br /> f Z <br /> ww <br /> a� TscD � <br /> a ) <br /> L g <br /> - QUANTITY LOST (GALLONS) <br /> w <br /> CAS A (ATTACH EXTRA SHEET IF NEEDED) NAME n/ S UNKNOW <br /> UO <br /> a j It) <br /> I- <br /> O UNKNOW <br /> M> <br /> (2) - <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE PCE MONITORING�-.� ,nQ <br /> 3,1 <br /> TANK; NUISANCE CONDITIONS 'RT OTHER: l•'� <br /> 1{M 2 '7D lY Y ❑ ROUTINE MONITORING ❑ REMOVAL �❑ <br /> METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLYS <br /> ww DATE DISCHARGE BEGAN UNKNOWN Q REMOVE CONTENTS ] REPLACE TANK [:]CLOSE TANK <br /> Ow <br /> 7� ` M 5D �Y ❑ ❑REPAIR TANK REPAIR PIPING ❑CHANGE PROCEDURES <br /> F <br /> '9m M `YD`D HAS DISCHARGE BEEN STOPPED? �7 �jj <br /> Od Y I M TY �`Y R <br /> ❑OTHE <br /> YES NO IF YES, DATE CAUSEIS} -�-� <br /> SOURCE(S) OF DISCHARGE -, - TANKS ONLY/CAPACITY GAt OVERFILL ❑CORROSION <br /> r r <br /> '-^ j ❑TANK LEAK ❑ JUNKNOWN AGE 1 D I YRS. ❑ UNKNOWN <br /> i 4 <br /> U MATERIAL _ CRUPTUR E/FAILURE [:]SPILL <br /> W PIPING LEAK ❑STEEL ❑FIBERGLASS <br /> � ❑ ❑UNKNOWN [:]OTHER <br /> D OTHER <br /> 0 ❑OTHER (SPECIFY) - <br /> -WATER SUPPLIES AFFECTED, ENED KNOWN WELLS <br /> RESOURCES AFFECTED, YES No THREATENED UNKNOWN YES; O <br /> p ❑ ❑ �_� PUBLIC DRINKING E] ❑ ❑ ��^ <br /> F AIR (VAPOR) WATER L-J# <br /> W SOIL {VADOSE ZONE) ❑ ❑ PRIVATE DRINKING ❑�. ❑ ❑ <br /> ❑ �� WATER <br /> W GROUNDWATER INDUSTRIAL ❑�,_ ❑ ❑ <br /> W C SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ UK <br /> r� ❑ ❑ - AGRICULTURAL O� ❑ ❑ <br /> W, BUILDING OR UTILITY VAULT L, ❑ OTHER(SPECIFY) .-❑x ❑ ❑ ❑ <br /> O OTHER (SPECIFY) Cl ❑ ❑ - <br /> O <br /> w GROUNDWATER BASIN NAME <br /> m J/ LNKNOWN <br /> COMMENTS: - r <br /> r N <br /> F- <br /> x <br /> w - <br /> f <br /> pH3C 05 {10/85) <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRArnING REPORT IF ANY CLEANUP WORK OR PLANNINGk HAS STARTED <br />