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M <br />NAUTHORIZED RELEASE (LEAK)/L"lJIQTAMINATION SITE REPORT <br />EMERGENCY <br />,/� HAS STATE OFFICE OF EMERGENC SE VICES <br />STATE TANK ID r ,/• <br />❑ YES �x NO REPORT BEEN FILED? ❑ YES NO <br />REPORT D%AAnTE 7qY <br />LOCAL CASE #REGIONAL <br />BOARD CASE # <br />US EPA ID # <br />UM � XD 7D 6 <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIG TURE <br />`fie <br />(9i& > � <br />m <br />w <br />REPRESENTING F-]LOCALAGENCY 0 OTHER <br />COMPANY OR AGENCY NAME <br />¢OWNER/OPERATOR <br />O <br />❑ REGIONAL BOARD <br />G, <br />aADDRESS <br />W <br />"717c ./ _ CITY .. . <br />3 �`8l <br />ST e-REET aJ �/ • L STATE IP <br />I > <br />NAME <br />CONTACT PERSON <br />PHONE <br />wr�Q <br />OZa <br />gon ❑-_`UN.KNOWN <br />1 <br />a <br />d W <br />ADDRESS <br />D^ ��y1 �/y�-/%� c�.y�/�S,Q % �] j/J� ,/),� yJ� %�j ,/� <br />50, D <br />K m <br />oo �f TRS' ° L -{TS / �G �' CITY iIZY // ! (.s' STATE�,,,�/! ZIP <br />FACILITY NAME (IF APPLICABLE) <br />',6n <br />OPERATOR <br />PHONE <br />4 <br />o <br />Aleno <br />irisi <br />a <br />O <br />ADDRESS <br />�9�g ,d�' A/a'J//�% L -T DZI V � �S�G �D�✓ �S-AN V,04fy'vi�✓ <br />J <br />S E CITY COUNTY ZIP <br />w <br />CROSS STREET <br />TYPE OF AREA COMMERCIAL ❑ INDUSTRIAL <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />`n <br />�TY <br />///LOCAL <br />RESIDENTIAL :RURAL ❑ OTHER <br />❑ UNKNOWN ❑OTHER <br />AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />z <br />- ry" <br />~ w <br />z - <br />W W <br />REGIONAL BOARD <br />-- <br />,� <br />(9r ),1�i - 67 <br />O <br />as <br />TSCD <br />E <br />w <br />O <br />CAS # (ATTACH EXTRA SHEET 1F NEEDED) NAME QUANTITY LOST (GALLONS) <br />` <br />—�UNKNOWN <br />rDWAr� <br />Q(11> <br />In K 1M <br />N DLY <br />m> <br />Nz <br />(2) I❑ UNKNOW <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL .❑ SUBSURFACE MONITORING <br />11Y <br />ROUTINE MONITORING ❑ TA <br />VAL X NUISANCE CONDITIONS E] OTHER - <br />}F <br />I D <br />REMONK <br />W W <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />V W <br />OmiM DIRYi 9YI ❑ UNKNOWN <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />M< <br />REPAIR TANK REPAIR PIPING CHANGE PROCEDURES <br />HAS DISCHARGE BEEN STOPPED? <br />YES ❑ NO IF YES, DATE 40M 7D Y Y <br />_ <br />y <br />OTHER 1 1Ke1Y OFA' I5'jCh PUMn <br />r <br />w <br />SOURCE(S) OF DISCHARGE <br />TANKS ONLY/CAPACITYC <br />GAL <br />_ AlWE(S) <br />�IOVERFILL <br />❑ TANK LEAK ,)❑ UNKNOWN <br />AGE W YRS. ❑ UNKNOWN <br />❑ CORROSION <br />W <br />❑PIPING LEAK <br />MATERIAL <br />RUPTURE/ FAILURE E]SPILL <br />jo04 f Jer00- <br />Ou STEEL �� FIBERGLASS <br />O <br />N <br />OTHER (SPECIFY) fj2C C39&0 #�tL4 <br />OTHER <br />❑UNKNOWN ❑OTHER <br />RESOURCES AFFECTE <br />YES NO THREATENED UNKNOWN <br />WATER SUPPLIES AFFECTED THREAT- - <br />YES NO ENED KNOWN WELLS <br />D <br />F <br />AIR (VAPOR) ❑ ❑ I-� <br />PUBLIC DRINKING ❑ "may ❑ <br />I�J <br />W <br />U. <br />SOIL (VADOSE ZONE) -I <br />❑ C� ❑ <br />WATER <br />PRIVATE DRINKING ❑ 1� ❑ ❑ <br />U. <br />U. 'GROUNDWATER <br />❑ CJ ❑ <br />WATER (, <br />W <br />SURFACE WATER OR STORM DRAIN ❑ El❑ <br />INDUSTRIAL El 156 E:1ED <br />¢Q <br />BUILDING OR UTILITY VAULT ❑ ❑ ❑ <br />AGRICULTURAL ❑ ❑ ❑ <br />0 <br />OTHER (SPECIFY) C� ❑ ❑ <br />OTHER (SPECIFY) ❑ ❑ ❑ <br />W <br />S <br />GROUNDWATER BASIN NAME <br />❑UUr�NNKNOWN <br />�'J�G ff �^ /� /� /� /� �J/ e, '-!� �J�--,.,�.�'/ `, <br />COMMENTS:. -7V6 /f�� �I� /tel' GV V��GCX"� /C.:GC.l.�� i <br />�7 G ��/ .4jeA /C� 'NIC.. IS /0 <br />z <br />: Ys-n5m Tf/, tic isrs .4r -r#E W.+rcz reom -Tfr civ p- <br />r)7sf� <br />m <br />PjSed_Aei� C6yt9W.441t��T�T�Eivie. 1tYE F96,44 iAn/C TZ/ <br />O <br />�7//r n(FF S (/1 <br />aN7i® rP�/y_Vi/�yKOA <br />CLEANUP WORG <br />OGMDPLfETOE AGND AACDA CLUP TRACKING IF <br />M <br />