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Poet-It'"brand <br /> Fax Transmittal Memo 7572 No.ofPages f Today's Date& /, fv Time <br /> To 5 � � From <br /> /D <br /> Company /UCXiY��v Company <br /> Location v( (� Location Dept.Charge <br /> Fax# Telephone# Fax# Telephone# <br /> Comma is Original <br /> Disposition: 1:1Destroy ❑Return Call for pickup <br /> I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)r.c"nITAMINAT I_ S E REPORT <br /> E,- GEN GY STATE TANK ID <br /> HAS STATE OFFICE OF EMERGENCY SE )GES 4I= <br /> ❑ YES NO REPORT BEEN FILEOT EDYES NO I I I II I I I <br /> REPORT DATE LOCAL CASE # REGIONAL BOARD CASE 0 US EPA ID R <br /> �?.1,41-7.j FY G'Y G 29 1990 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> �TAL HEALTH <br /> O REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPA OR AG ICY NAME <br /> w <br /> ROj2p OWNER/OPERATOR ❑ REGIONAL BOARD G <br /> 0. ADDRESS 1 <br /> w 370 7 1�In s f �u�.� �! 1�1�a�'��Uj� S�rc�..�►���- O < IP <br /> STREET CITY STATE ZIP <br /> 1 > NAME CONTACT PERSON PHONE <br /> zX • / ❑ UNKNOWN <br /> O <br /> 1ar,w ADDRESS � <br /> )�7 ,�(�' /y�„rv� \ .•�{�J / <br /> ¢m �70 K1� TRS E�X/r f CITY STATE ZIP <br /> FACILITY NAME (IF APP CABLE) OPERATOR r re- 41 Ci`- PHONE <br /> 0 C1 <br /> C,, (aop <br /> ~ ADDRESS <br /> J COUNTY ZIP <br /> STREET CITY <br /> w CROSS ST EET TYPE OF AREA COMMERCIAL [:]INDUSTRIAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> �f� RESIDENTIAL []RURAL Q OTHER ❑UNKNOWN OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PER/SON PHONE <br /> 411- <br /> Hw REGIONAL BO RD <br /> Z <br /> w V- <br /> 2z <br /> ww <br /> a.¢ TSCD <br /> w CAS a (ATTACH EXTRA SHEET IF NEEDED) NAMD QUANTITY LOST (GALLONS) <br /> a> (I) I ' I UNKNOW <br /> F J <br /> 140 <br /> M> <br /> N= (Z) 1 L J I I I I I I I I I I 11 UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING <br /> yH MI MI D D Y y ❑ ROUTINE MONITORING TANK REMOVAL E] NUISANCE CONDITIONS E] OTHER: <br /> ww DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> ow MI MI DI 01 YJ YJ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> V <br /> �m HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK <br /> _]REPAIR PIPING I�CHANGE PROCEDURES <br /> YES F7 NO IF YES, DATE I M1 MI DI 01 yj y ❑OTHER <br /> LU URCE(S) OF DISCHARGE TANKS ONLY/CA PACITY 3U �~ GAL CAUSEIS) <br /> ❑TANK LEAK CX UNKNOWN ❑OVERFILL ❑CORROSION <br /> a AGE W YRS. UNKNOWN <br /> w I�PIPING LEAK MATERIAL ❑RUPTURE/FAILURE E]SPILL <br /> STEEL ❑ FIBERGLASS <br /> M <br /> a F-1OTHER (SPECIFY) C:]OTHER i�IUNKNOWN [:]OTHER <br /> RESOURCES AFFECTED YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED TH - <br /> YES NO ENED KNOWN WELLS <br /> ❑ ❑ C] PUBLIC DRINKING <br /> AIR (VAPOR) ❑ El <br /> ^ ryy <br /> El w SOIL (VADOSE ZONE) WATER - l_I L/.!7 <br /> W ❑ ""'� ❑ PRIVATE DRINKING ❑ ❑ a <br /> <Y GROUNDWATER Q ❑ ❑ WATER <br /> m� SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ INDUSTRIAL ❑ ❑ ❑ <br /> Q`F BUILDING OR UTILITY VAULT Wr _ ❑ ❑ ❑ AGRICULTu RAL ❑ ❑ ❑ Ur <br /> =OOTHER (SPECIFY) L� ❑ El ElOTHER(SPECIFY) ❑ ❑ ❑ ❑ <br /> u) <br /> w <br /> S GROUNDWATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS: <br /> H <br /> S <br /> w <br /> E <br /> 2 <br /> O <br /> V <br /> COMPLETE AND ATTACH A CLEANUP TRA IG REPORT IF ANY CLEANUP WORK OR PLANNIN'V'eAS STARTED 43C05 (10/851 <br />