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AL <br /> low <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMI T N.SITIr\Ft9RQRT `- <br /> EMPRGENCY AS STATE OFFICE OF EMERGENCY SERVICES 5TATE TANK ID <br /> J YES NO REPORT BEEN FILE01 __ YES NO � 01I (ti {li �j`I �q & �.t <br /> VEPORT DATE LOCAL CASE n REGIONAL BOARD CASE T]S ERA iC•x - <br /> CT Tn L <br /> I M Mi 6 LD1 vyl r III111t TLJ <br /> NAME OF INDIVIDUAL FILING r ��,,REPORT PHONE SIGNATURE TAI <br /> AI L <br /> m �5 +Lf �,a r-,n L c,, o __SL- ( q15 ) +/��r�l— 319,1 M L <br />' O REPRESENTING LOCAL AGEN Y OTHER COMPANY OR AGENCY NAME <br /> ~ OWNER/OPERATOR 1 REGIONAL BOARD <br /> b ADDRESS <br /> STREET CITY STATE ZIP <br /> I >- NAME CONTACT PERSON PHONE <br /> D4 S! _L..x Sal���� enc_ ',� UNKNOWN , ....1 \ 4L.� 1�1\V �� (z } !.7 <br /> c_ ADDRESS n` ( r in <br /> W-� I y`� -3 �v-'�� Lv. i^Gl1r� -r-'Y {l <br /> STRE T CITY STATE ZIP <br /> FACILITY NAME IIF APPLICABLE) OPERATOR PHONE <br /> 1 < AObRE 5 <br /> U <br /> O STREET CITY COUNTY ZIP <br /> J <br /> CROSS STREET TYPE OF AREA �I COMMERC4AL INDUSTRIAL TYPE OF BUSINESS ,,; Ft!<TAI FUEL STAT ICN ' <br /> 7 1 RESIDENTIAL / {� �f <br /> �i RVRAL i OTHER r i UNKNOt•'/N I OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z� <br /> e ) q6L - 642 <br /> =w REGIONAL BOARV <br /> 10 U <br /> 72 <br /> LLJ <br /> a TSCD <br /> ( 1 I <br /> i <br /> Oa CAS i (ATTACH EXTRA SHEET IF NCEDED) NAME , I QUANTITY LOST {GALLONSI <br /> 4 j (1 1 I ' ' I f I I ' I 1 j Pc7�� li C�1I UNKNOWt� <br /> O <br /> mJ <br /> N (2) I <br /> + UNKNOWN <br /> DATE DISCOVERED �H--O--77W DISCOVERED INVENTORY CONTROL lJ SUBSURFACE M`O/NITORING <br /> }� 0MI IMS � qD S �r L.J TAN <br /> ROUTINE MONITORING iJ REMOVAL C I NUISANCE CONDITIONa Y I OTHER <br /> amu. DATE DISCHARGE BEGAN ` METHOD USED TO STOP DISCHARGE (CHECK ALL. -HAT APPLY) <br /> > — <br /> DF MI M. D D' Y' Y UNKNOWN JCI REMOVE CONTENTS I REPLACE TANK CLOSE <br /> `n4NAS DISCHARGE BEEN STOPPEO� + + u <br /> Oc ` REPAIR TANK REPAIR PI PINU CHANGE PROCEDURES <br /> �YE5 NO IF YES DATE M! MI 01 D1 yj Y L_OTHER <br /> SOURCEISI OF DISCHARGE TANKS ONLY/CAPACITY 1 Ucx!) GAL CAUSES) <br /> TANK LEAK UNKNOWN OVERFILL CORROSION <br /> 4 AGE L I 1 YRS UNKNOWN <br /> U <br /> w +PIPING LEAK MATERIAL RUPTURE/FAILURE � SPILL <br /> r =STEEL i Y! FIBERGLASS J <br /> O OTHE= SS PECIFYI �OTHER {y I UNKNOWN � OTHER <br /> WATERSUPPLIESAFFECTED TH 1 UN- <br /> RESOURCES AFFECTED <br /> YES �No <br /> THREATENED UNKNOWN YES NO CNCDKNOWN WELLS <br /> W AIR IVAPORI (y 1 r� IT� PUBLIC DRINKING <br /> !� WATER <br /> w SOIL IVAgOSE ZONE) n 1 <br /> 4 � PRIVATE DRINKING r� <br /> LL GROUNDWATER 11 4� WATER L- I <br /> cn= SURFACE WATER OR STORM DRAIN `J �i� INDUSTRIALWIX <br /> Jr 9UI�JING OR UTILITY VAULT � �� � AGRICULTURAL <br /> OTHER ISPEUFY} OTHERISPECIFYI 1 `I `I <br /> GROUNDWATER BASIN NAME �� <br />' UNKNOWN <br /> =CI+KENTS <br /> 7 <br /> CCmPI_ETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED C <br />