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r <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br />EMERGENCY <br />HAS STATE OFFICE OF EMERGENCY SERVICES <br />YES NO REPORT BEEN FILED? ❑ YES Cg_ NO <br />STATE TANK ID <br />REPORT DATE LOCAL <br />CASE k <br />REGIONAL BOARD CASE N <br />US EPA ID N <br />M M D D Y Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />S N A, UR <br />t"7 ��c�v-a � 7 <br />w <br />REPRESENTING �❑ LOCAL AGENCY ❑ OTHER <br />COMjP�A�N{YY OR AGENCY NAnM�Ef-�� / �r <br />�/l.J �`--'� r„R(!YI�� �` <br />OWNER/OPERATOR ❑ REGIONAL BOARD <br />/`(1� / G' L-- <br />d <br />w <br />ADDRESS /�� �/ �J <br />/ j <br />��©� /'�_ /�Yn.� �e� �GC�i _� uI c� CI�J ��/I a QCT- 'C.C, !'�„ `I' TO �3 <br />(� <br />STREET CITY STATE ZIP <br />^ F <br />NAME _ _ � <br />CON//T11tAC�1T ' , /� ,% <br />PH�O]'N1E�J ^� <br />(/ o /)L��' / <br />a <br />�� ❑ UNKNOWN <br />�P�E%RSON <br />l._. C✓.� i , Li!��%/1.. <br />O< <br />4. W <br />'�J-i.�'V <br />-� <br />ADDRESS % % G� ��1 / �i _ T.� �i�� 1 to I / '-A e° I c `. %��. 7 \, <br />Erm <br />STREET /""/"" CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) JOPERATOR <br />�zt/�►' <br />PHONE <br />a <br />" exS <br />qU <br />,cm <br />vd. ADDRESS 2C o �ij of 7) k -t / l �✓I ! �r�/ Y� `.J/ C�Vh..: 7''l.� ��'� _.� L�� l� 7��i>� <br />O <br />J <br />,/ <br />STREET CITY COUNTY ZIP <br />W <br />CROSS STREET <br />TYPE OF AREA COMMERCIAL ❑ INDUSTRIAL <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />P% -n o -u -H ,i- <br />�� RESIDENTIAL U RURAL F-] OTHER <br />UNKNOWN ❑ OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />U <br />f z <br />RE G�N B R <br />/G�7 <br />�pey +�,2rht <br />wW <br />IF"Ti 6V /G�.C.K <br />a a <br />TSCD <br />F <br />- <br />c ) <br />w <br />UO <br />CAS 8 (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br />ti z, ��T�r.) <br />a> <br />_❑ UNKNOW <br />♦ J <br />nO <br />m _> <br />u7i ` <br />n UNKNOW <br />(2) <br />DATE DIS��C99OVERED`a� <br />HOW DISCOVERED ❑ INVENTORY CONTROL F-1 SUBSURFACE MONITORINGTANK <br />yF <br />s"11 <br />bM SM 'ADDI 4I "Y r Y <br />❑ ROUTINE MONITORING ❑ REMOVAL E� NUISANCE CONDITIONS OTHER: <br />WW <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />>2 <br />O W <br />M M D D Y- YJ UNKNOWN <br />REMOVE CONTENTS REPLACE TANK f CLOSE TANK <br />UI <br />Om <br />4 <br />i.JREPAIR TANK .REPAIR PIPING ❑CHANGE PROCEDURES <br />HAS DISCHARGE BEEN STOPPED? <br />YES NO IF YES, DATE I Ml MI DI DI Y Y <br />❑OTHER <br />SOURCE(S) OF DISCHARGE <br />TANKS ONLY/CAPACITY GAL <br />CAUSE(S) <br />j <br />❑TANK LEAK � UNKNOWN <br />' I ' <br />AGE W YRS. UNKNOWN <br />❑OVERFILL ❑CORROSION <br />w <br />�] PIPING LEAK <br />MATERIAL <br />`1 RUPTURE/ FAILURE EISPILL <br />U <br />cr <br />❑ STEEL ❑ FIBERGLASS <br />O <br />-OTHER (SPECIFY) <br />❑OTHER {�h y� �i <br />UNKNOWN OTHER <br />❑ <br />RESOURCES AFFECTED <br />YES NO THREATENED UNKNOWN <br />WATER SUPPLIESAFFECTED H - <br />YES NO ENED KNOWN WELLS <br />HAIR <br />(VAPOR) El El �_] <br />PUBLIC DRINKING rr <br />WATER El ED 1---1 - X[ <br />W <br />1., <br />SOIL (VADOSE ZONE) 391 <br />°��` ❑ El ❑ <br />PRIVATE DRINKING ❑ ❑ n <br /><Y <br />GROUNDWATER ❑ Cl ❑ <br />WATER <br />W K <br />SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ <br />INDUSTRIAL E-1 ❑ CJ <br />UI- <br />BUILDING OR UTILITY VAULT ❑ ❑ ❑ <br />AGRICULTURAL El❑ ❑ 0-;dMa <br />OTHER (SPECIFY) El El <br />OTHER((SPECIFY) ❑ ❑ X ❑ <br />GROUNDWA/TER BASIN NAME®I7eou <br />`il C UNKNOWN <br />COMMENTS: <br />pre.vluv�, vucrK� b� Eme-o*teI--0cf4,4"- <br />- �rie4ls?x uc abs- ,h ErNc-0/v , `7'l�urcf� 1r9 c <br />O <br />U <br />COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED ,SSC 05 (10/55) <br />