Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY STATE TANK ID a <br /> r l HAS STATE OFFICE OF EMERGENCY SERVICES <br /> � YES NO REPORT BEEN FILED? 0 YES NO <br /> REPORT DATELOCAL CASE # REGIONAL BOARD CASE # US EPA ID # <br /> � <br /> OM M /D 9Y / Y <br /> NAME OF INDIVIDUAL FILING REPORTPHONE SIGNATURE <br /> orn— acq? ) <br /> O REPRESENTING LOCAL AGENCY 0 OTHER COMPANY OR AGENCY NAME <br /> W <br /> ¢ OWNER/OPERATOR a REGIONAL BOARD <br /> O <br /> a ADDRESS <br /> Ir <br /> �/Y� 5�., ✓o���•�� Ste, s,4��,E�or, c� 4 s'�o i <br /> STREET _ CITY STATE ZIP <br /> > NAME ,(� CONTACT PERSON PHONE <br /> p¢ // 1f c �Pi�j'D/BLl/'� UNKNOWN G ci &er � <br /> /.� i-�1 ( ZO�f ) d 3-Y7 i--C— <br /> a W ADDRESS <br /> LU_j >/G SEI)' moi[ Gf/J 7�c GG` C� �S.33�p <br /> r J <br /> 1:m STREET CITY STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> o iPG # �0�0 �� Bc �� ( 7�9 > �Z3- v?/ <br /> ADDRESS E O.S��7/.�PQ�2 G�— � <br /> O <br /> V � <br /> 1711STREET CITY COUNT ZIP <br /> J _ <br /> w CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL TYPE OF BUSINESS TAIL FUEL STATION <br /> F <br /> m /V�, IEJ RESIDENTIAL LJ RURAL F-�OTHER [ j UNKNOWN 0 OTHER <br /> LOCAL AGE14CY AGENCY NAME CONTACT PERSON PHONE <br /> zw REGIONAL BOARD <br /> W V <br /> fz ( ) <br /> ww <br /> a a TSCo <br /> f <br /> W CAS # (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> UO <br /> UNKNOW <br /> <> (1) lC�c GlGfy 9 Ci SO�/tiQ_ <br /> F-J <br /> 00 <br /> m> <br /> N: (2) UNKNOW <br /> \ DATE DISCOVERED HOW ROUTNE MONITORING <br /> COVERED <br /> I ❑ INVENTORANKONTROr 1 SUBSURFACE MONITORING <br /> }F M � Y 0 REMOVAL LJ NUISANCE CONDITIONS , OTHER: <br /> Wz <br /> W DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> O W M M D DI YI Y UNKNOWN 0 REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> V� <br /> 0 m HAS DISCHARGE BEEN STOPPED? REPAIR TANK a REPAIR PIPING CHANGE PROCEDURES <br /> 4 <br /> YES ONO IF YES, DAT M M D D Y Y ❑OTHER <br /> w <br /> SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITYZ7�J�(] GAL CAUSES) <br /> E]TANK LEAK UNKNOWN OOVERFILL El CORROSION <br /> AGE YRS. O UNKNOWN <br /> W PIPING LEAK MATERIAL lJ RUPTURE/FAILURE EI SPILL <br /> V <br /> m �STEEL FIBERGLASS <br /> O OTHER (SPECIFY) F-�OTHER O UNKNOWN [�]OTHER <br /> THREAT-\ RESOURCES AFFECTED YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED EKED KNOWN WELLS <br /> f AIR (VAPOR) D El J PUBLIC DRINKING r, [Zr <br /> W SOIL (VADOSE ZONE) r l�7. WATER LJ I_J u <br /> ti C�� a PRIVATE DRINKING D El <br /> W GROUNDWATER �� � WATER L_J <br /> W SURFACE WATER OR STORM DRAIN El � El INDUSTRIAL El El D <br /> 2~ BUILDING OR UTILITY VAULT E:l AGRICULTURAL 0 0 0 0 <br /> 00a OTHER (SPECIFY) El ❑ 0 u OTHER(SPECIFY) El El O O <br /> W <br /> W <br /> 5: GROUNDWATER BASIN NAME <br /> Ev�`UNKNOWN <br /> COMMENTS: <br /> Nessa Ay <br /> i►,i/ /�7n�f �Zl6�c��cl /Lct��1G� GCS --e 4 Ike-al <br /> O <br /> COMPLETE AND ATTACH A CLEANUP ANLTR��NGlREPOORR'T IF ANY CLEANUP WORK OR PLANNING HAS STARTED 145C 05 (10/e5) <br />