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UNDERGROUND STORAGE Ts UNAUTHORIZED RELEASE ( LEAK) / . NTAMINATION SITE REPORT <br /> EMERGENCY <br /> YYw HAS STATE OFFICE OF EMERGENCY SERVICES STATE TANK 10 # <br /> YES � I NO REPORT BEEN FILED? YES NOI i I I I I I I <br /> II IkAI <br /> REPORT DATE LOCAL CASE REGIONAL REGIONAL BOAR/�D CASE # US EPA ID # . ' '1 <br /> M M D O Y /y A <br /> NAME OF INDIVIDUAL FILING REPORT P SI TUR <br /> m rl ( 5 ! - <br /> O REPRESENTING 0 LOCALAGENCY Q OTHER COMPANY OR AGENCY NAME <br /> W <br /> ROWNER/OPERATOR Q REGIONAL BOARD TA a /� n . / <br /> p - h !�I A <br /> W ADDRESS /� /` /� 9�foa <br /> goon STREET&., 1njC:j/Q '1715 ! V 4,(' CITY 5 d STATE C��'T ZIP <br /> I > NAME CONTACT PERSON PHONE <br /> z UNKNOWN l 'J07 ) .y 2 - JIAA <br /> a - <br /> ADDRESS - �I� <br /> STREET Q� CITY F1 ' STATE L�.fy ZI� <br /> FACILITY NAME ( IF APPLICABLE) OPERATOR PHONE <br /> s S7A AI C 1 ' lY P�$ ca709 > � <br /> R ADDRESS <br /> SRI JoRq�/nl /%5210 <br /> O716 & STREET L �T CITY ST COUNTY ZIP <br /> J <br /> FW- CR SS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL TYPE OF BUSINESS 5F RETAIL FUEL STAT ION <br /> RESIDENTIAL 0 RURAL Q OTHER EJUNKNOWN QOTHEft <br /> OCAL AGENCY AGENCY NAME CONTACT PERSON- PHONE - <br /> _ 9zm .1 M n)rA <br /> REGIONAL BOARb RG ZAv ii5 dLEULLA (. 676/ <br /> W W D <br /> WD <br /> F Z ) <br /> uwi Al 1A <br /> da TSCO A ' <br /> / Y <br /> yl IA <br /> CAS # (ATTACH EXTRA SHEETIF NEEDED) <br /> NAME QUANTITY LOST (GA,�L--LLONS) <br /> UO <br /> JIC G 11 ) - L . jI� Ll 671 T 0 = lO JXIUNKNOW <br /> FO T� <br /> m > <br /> 121 <br /> UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED Q INVENTORY CONTROrLL,, ❑ SUBSURFACE MONITORING <br /> Y <br /> ROUTINE MONITORING ❑ 'TANKREMOVAL LJ NUISANCE CONDITIONS O OTHER : <br /> > bovul <br /> W W DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> OF M M ❑ 0 V YJ UNKNOWN Q REMOVE CONTENTS Q REPLACE TANK CLOSE TANK <br /> om HAS DISCHARGE BEEN STOPPED? )� REPAIR TANK REPAIR PIPING E::] CHANGE PROCEDURES <br /> YES Q NO IF YES, DATE M 4M D `(JD geiJy ED OTHER <br /> II <br /> W SOURCES) OF DISCHARGE TANKS ONLY/CAPACITY (fN KAIn I:I] . GAL CAUSE(S) <br /> j <br /> E:] TANK LEAK UNKNOWN I I 1 �/, OOVERFILL E] CORROSION <br /> Q AGE W YRS , D( I UNKNOWN <br /> R PIPING LEAK MATERIAL I�� V RUPTURE/ FAILURE SPILL <br /> STEEL FIBERGLASS <br /> w [D OTHER (SPECIFY ) QOTHER UN �'Ala it k) OUNKNOWN QOTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED T H RR T- - <br /> YES tttNrr�O--mss THREATENED UNKNOWN YES NO ENED KNOWN WELLS <br /> 1- AIR (VAPOR) Q Ll PUBLIC DRINKING ^ ❑ <br /> w SOIL (VADOSE ZONE) �U�(�l{I WATER �I <br /> < � ' GROUNDWATER Q LJ WATER PRIVATE DRINKING - •� O <br /> w � SURFACE WATER OR STORM DRAIN O ED 11 INDUSTRIAL Q )K Ll ❑ <br /> UI BUILDING OR UTILITY VAULT D E:l 0 l< AGRICULTURAL � � <br /> JOa OTHER (SPECIFY ( El O Q � OTHER (SPECIFY) E ❑ ❑ <br /> W <br /> Z GROUNDWATER BASIN NAME <br /> [-] UNKNOWN <br /> COMMENTS : <br /> � �I7 <br /> W <br /> f <br /> 0 <br /> D <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED H5c 05 ( 10/e5) <br />