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e <br /> �}TY <br /> UNDERGROUND STORAGE T I{ UNAUTHORIZED RELEASE (LEAK)'4V.TAMINATION SITE REPORT <br /> EVIFRGENCY STATE TANK 1D .= <br /> I HAS STATE OFFICE OF EMERGENCY 5 VICES � <br /> ✓r e <br /> YES NO REPORT BEEN FILED? E] YES NO <br /> REPORT DATE LOCAL CASE # REGIONAL BOARD CASE # US EPA ID <br /> a # <br /> M D D Y Y l i,:' • 1L a <br /> NAME OF INDIVIDUAL FILING REPORT PHONE <br /> $1 URE Et,�•.-I /CE�.�If clic <br /> 1D L ,2 1 <br /> 0 REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPANY OR AGGENC NA / 't., Cop <br /> WNER OPERAT[OR.;y� r » ❑ REGIONAL BOARD �G' G�s�'� L o/'�y�� <br /> EL AD RESS 9;w '3 Z�AIPl2! 1& 04'00) d, / ��SN�� V <br /> (K J ^� <br /> STREET v�/ e _�rI4 CITY STATE ZIP <br /> /},�� f CONTACTAPERSON PHONE 97/ / <br /> � I <br /> Z4 ME L/yIVA / LJ UNKNOWN jJ� L�iU.� I(YI_6�) !M3 <br /> �f /I + <br /> a w ADD}DRESS sgzo <br /> aM STREET }L.��/)-4f^ VQ CITY STATE ZIP <br /> FACILITY NAME IIF APPLICABLE) OPERATOR PHONE <br /> UADDRESS el//Qlv�/Y,L'� / ��]�/�1 3IT/✓ cCv/N / .7,j(�/ 1 <br /> O STREET CITY COUNTY ZIP <br /> J <br /> W CROSS STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL TYPE OF BUSINESS RETAIL FU L SSATI�]N <br /> N 0IVVf,v1�'jfF"j <br /> A� ESIDENTIAL RURAL [—]OTHER ❑UNKNOWN OTHER <br /> L CAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> JOR viiv S Ll'31-1 /F CaTlJLLA <br /> i REGIONAL BOA N TL's fA q <br /> Lu U <br /> Fw <br /> W <br /> Jq 75C0 <br /> a <br /> f <br /> w CAS X (ATTACH EXTRA SHEET IF NEEDED) �NAME .L1 /Y�!/�! 1y' QUANTITY LOST (GALLONS) <br /> j I11 �/v L��JL�LcI J� /✓� A 1��/� ��Od- - --❑UNKNOW <br /> F J <br /> N O <br /> mz I UNKNOW <br /> (2) <br /> DATE DISCOVERED NOW DISCOVERED ❑ INVENTORY CONTROL 11 ❑ SUBSURFACE MONITORING !I <br /> }r EY 6 Y ❑ <br /> ROUTINE MONITORING ❑ REMOVAL LJ NUISANCE CONDITIONS OTHER:ZR&K LJNl� <br /> w W DATE DISCHARGE BEGAN Uj., METH USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> Ow I M D I Y ❑ UNKNOWN REMOVE CONTENTS L REPLACE TANK ❑CLOSE TANK <br /> �ca I HAS DISCHARGE BEEN STOPPED? `1 REPAIR TANK IJ REPAIR PIPING C]CHANGE PROCEDURES <br /> 4 <br /> E5 NO IF YES, DATE M Y Y ❑OTHER <br /> w SOURCE(S) OF DISCHARGE TANKS ONLYl-CAPACITY GAL CAUSE(S) <br /> In <br /> �JTANK LEAK ❑ UNKNOWN ❑OVERFILL 000RROSION <br /> a AGE 1� YRS. ❑ UNKNOWN <br /> w f PIPING LEAK J>f?0AA4► MATERIAL ❑RUPTURE/FAILURE ]SPILL <br /> U STEEL ❑ FIBERGLASS <br /> ON ❑OTHER (SPECIFY) [::]OTHER UNKNOWN ❑OTHER <br /> ` RESOURCES AFFECTED THREAT- UN- <br /> YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED ENED KNOWN WELLS <br /> N AIR (VAPOR) ❑ C1 Ci PUBLIC DRINKING r-I r� FD <br /> WSOIL fVADOSE ZONE) WATER LJ LJ <br /> LL ® ❑ �� ❑I PRIVATE DRINKING ❑ ❑ C"-1 <br /> E GROUNDWATER ❑ 0 El WATER LJ <br /> w� SURFACE WATER OR STORM GRAIN ❑ O ❑ I?? INDUSTRIAL L� ❑ ❑ <br /> ¢~ BUILDING OR UTILITY VAULT L�J ❑ ❑ AGRICULTURAL ❑ ❑ ❑ <br /> 0� OTHER (SPECIFYI �� ❑ 0 OTHER fSPEC1FYI <br /> F-1 ❑ ED <br /> w <br /> X. GROUNDWATER BASIN NAME <br /> UNKNOWN <br /> COMH£NTS: <br /> in <br /> H <br /> z <br /> w <br /> E <br /> 0 <br /> u <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED risc 05 (10/135) <br />