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rl <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br />EMERGENCY <br />HAS STATE OFFICE OF EMERGENCY SERVICES <br />LJ YES 64_NO REPORT BEEN FILED? ❑ YES b4_ NO <br />STATE TANK ID i. <br />REPORT DATE <br />LOCAL CASE >t <br />REGIONAL BOARD CASE N <br />US EPA ID H <br />(' �J <br />QM s" (o D "Y / Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />!TG(� � S1`I.Q,P✓ � <br />(4/55 474- 3 ® <br />LOCAL AGENCY OTHER <br />COMPANY OR AGENCY NAME <br />T�racC '% <br />(,.j..y <br />OREPRESENTINGOWNER/OPERATOR <br />REGIONAL BOARD <br />m u cf s v/i_p <br />W <br />(� Jam/ � ` / '/❑^ / N //O �� /�..cv % /�Re:.tY <br />ADDRESS 4-ffg5 Wood -j -h <br />C]'�4!5-6 <br />ko!/(•,(i6. Ptie c;w(. n V/-- eA ! 4! 6 !O <br />� '5k <br />CITY STATE ZIP <br />OC <br />�V .rVSSTR,E/EET� // <br />NAMEC/V ! �//"VtiC/ti/�Y( I�Ot I✓ SUNKNOWN <br />CONTACT <br />yy-�/�, �j� p <br />�.J <br />/�f�P�SO�P AUJZ <br />o W <br />W J <br />ADDRESS <br />.-© CSO vYc l? rLu� c e lata PVI&/J- Su k' /)It -on CA X1 4 3 <br />M <br />STREET U CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />rq'l2 CU cS'�zc <br />x� 2 /3. -3 <br />5 zt cc ro( <br />c = o q) 79 - 55$"55 2 <br />o <br />b\� „`. <br />UADDRESS <br />O <br />j�/� p /vac <br />% 01?1 /�.'(/G��/r°/C 7 J�%%iY�• S�IIL ��iGT �UCi�ij�l%� ISZ.®". <br />J <br />STREET CITY COUNTY I ZIP <br />La <br />CROSS STREET�/� ,% <br />f 1 kd <br />TYPE OF AREA COMMERCIAL ❑ INDUSTRIAL <br />-] <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />grnol%T vL ° IF] <br />RESIDENTIAL L RURAL ❑ OTHER <br />UNKNOWN ❑ OTHER <br />ZN <br />LOCAL AGENCY AGENCY NAME <br />Sa.,L-Jo et ,) -t_ h l-oc-,J zkgfjf - <br />CONTACT PERSON <br />PHONE <br />W <br />z — <br />REGIONAL BOARD <br />W U <br />Y Z <br />W W <br />a a <br />TSCD <br />W <br />CAS d (ATTACH EXTRA SHEET IF NEEDE�D�)) NAME QUANTITY LOST (GALLONS) <br />UO <br />a, <br />] <br />(1) I Ka! C�I J _. UNKNOW <br />00 <br />M> <br />(2) 1 1 1 1 1 UNKNOWN <br />DATE DISCOVERED <br />HOW DISCOVERED F-1INVENTORY CONTROL E:]SUBSURFACE MONITORING <br />>-TANK <br />I <br />Gr �/ <br />uM D /Mj:ZD OD YY17yY <br />❑ ROUTINE MONITORING 1LREMOVAL [-] NUISANCE CONDITIONS OTHER: <br />¢Z <br />W W <br />>2 <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />!'ek"L 6"Qi <br />ULW.. <br />M MI D D Y Y UNKNOWN <br />REMOVE CONTENTS �iiEk'.i:.M16E TANK ❑CLOSE TANK <br />wQ <br />L] REPAIR TANK [::]REPAIR PIPING U CHANGE PROCEDURES <br />HAS DISCHARGE BEEN STOPPED? <br />//�� 2�J <br />V <br />YES ❑ NO IF YES, DATE I M �M D o D �Y / Y <br />❑ OTHER <br />W <br />SOURCE(S) OF DISCHARGE <br />TANKS ONLY/CAPACITY .57!5- t) GAL <br />CAUSE(S) <br />D <br />a <br />TANK LEAK F-1UNKNOWN' <br />t 1 <br />AGE W YRS. P< UNKNOWN <br />D OVERFILL CORROSION <br />U <br />w <br />0PIPING LEAK <br />MATERIAL <br />[,] RUPTURE/ FAILURE [SPILL <br />IrSTEEL <br />❑ FIBERGLASS <br />0 <br />I❑ OTHER (SPECIFY) <br />❑ OTHER <br />❑ UNKNOWN D OTHER <br />� <br />RESOURCES AFFECTED <br />YES NO THREATENED UNKNOW N <br />WATER SUPPLI ES AFFECTED H - OF <br />YES ENCD KNOWN WELLS <br />UAIR <br />(VAPOR) ❑ ❑ ❑ �"-" <br />PUBLIC DRINKING ❑ , r� - <br />1 J <br />El <br />w <br />SOIL (VADOSE ZONE) p�7f ❑ <br />K❑� ❑ <br />WATER <br />W <br />aY <br />GROUNDWATER g[�l <br />❑ L^J ❑ <br />WATER DRINKING ❑ 1— ❑ <br />n <br />W <br />SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ <br />INDUSTRIAL ❑ ❑ ❑ Eg <br />xa I- <br />BUILDING OR UTILITY VAULT 1-1❑ 1:1 RL <br />AGRICULTURAL ❑ ❑ ❑ <br />D <br />u> <br />OTHER (SPECIFY) [l ❑ ❑ ❑ <br />OTHER(SPECIFY) ❑ 0 ❑ ❑ <br />W <br />S <br />GROUNDWATER <br />BASIN NAME <br />Saki <br />"Jo In ❑UNKNOWN <br />COMMENTS: <br />z <br />Z <br />W <br />E <br />f <br />O <br />U <br />COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED H>C 05 (10/88) <br />