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#f <br /> SIM <br /> UNDERGROUND STORAGE TA UNAUTHORIZED RELEASE (LEAK)/ TAMINATFDN S��E REPORT^ <br /> EMERGENCYSTATE TANK ID: <br /> XAS STATE OFFICE OF EMERGENCY SERVICES E VI OM .N <br /> F-1YESW NO REPORT BEEN FILED? E] YES Cl NO I Op�,I p <br /> REPO''R'fT DATE 'S <br /> LOCAL CASE k REGIONAL BOARD CASE A US EPA FIERMI� SERVICES <br /> am 144 QD (OD SY Y AXONE SIGNATUR <br /> NAME OF INDIVIDUAL FILING REPORT <br /> JoNu J. -71 - cal3 ) 34�•5oso <br /> W REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COM`P`ANY OR AGENCY NAME <br /> oOWNER/OPERATOR ❑ REGIONAL BOARD L)SA p�rrzo�,Eveh y1 <br /> W ADDRESS �/�T r 54,VJA M,0AJICA LSA /ollo� <br /> G S'a.0 ��o A.D LU/S� "" t N CLEJ�12 CITY STATE ZIP <br /> STREET PHONE <br /> CONTACT PERSON <br /> I> NAME <br /> fj <br /> iw LL UNKNOWN <br /> Oa <br /> a <br /> Wj ADDRESS CITY STATE ZIP <br /> WWO, STREET PHONE <br /> FACILITY NAME (IF APPLICABLE) OPERATOR <br /> ( <br /> o USA C�ASOLt/L[E 'IF � �a <br /> < ADDRESS s�ac�-ate Sa, J6At�vrN <br /> o alSa /IrIg21POSA 2a CITY cou+rY <br /> J STREET RETAIL FUEL STATION <br /> W TYPE OF AREA COMMERCIAL ❑INDUSTRIAL TYPE OF BUSINESS <br /> f CROSS STREET .. <br /> ❑UNKNOWN ❑OTHER <br /> (^�Q��AIVTGAl ��RESIDENTIAL ❑RURAL ❑OTHER <br /> LOCAL AGENCY AGENCY NAME <br /> CONTACT PERSON HONE <br /> 5,a . -104pA vrJ ycA�TN /JIfRa KH4,vN4 P <br /> I-W REGIONAL BOARD <br /> ZU <br /> WI <br /> FW <br /> Ja TSCD <br /> '- QUANTITY LOST (GALLONS) <br /> W CAS i (ATTACH EXTRA SHEET IF NEEDED) ^^NAME •.e- _�UNKNOW <br /> uD ( �ASOLIhtE <br /> a> tl) <br /> J <br /> w O n UNKNOW <br /> M> <br /> N= (21 <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING <br /> c ROUTINE MONITORING ❑ REMOVAL ❑TANKNUISANCE CONDITIONS El OTHER: <br /> yI- QM3M •AD OO OI Y ❑ <br /> ,Z <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> >f REMOVE CONTENTS ❑ REPLACE TANK ❑CLOSE TANK <br /> of M M D D Y V UNKNOWN ❑ <br /> .< HAS DISCHARGE BEEN STO PPE07 ❑REPAIR TANK ❑REPAIR PIPINu' ❑CHANGE PROCEDURES <br /> 2i m a [AOTHER TAAHCS�F'Pl ne.0 Ca ef1c.CJ<e.b;NO 4EA I<S <br /> VES NO IF VES, GATE M M D D Y Y U CA USElS) <br /> SOURCE(S) OF DISCHARGE TANKS ONLY[CA PACITY GAL ED <br /> OVERFILL E]CORROSION <br /> W <br /> ❑TANK LEAK UNKNOWN AGEI I 1 YRS. ❑ UNKNOWN <br /> u MATELRI_AJL—J ❑RUPTURE/FAILURE ]SPILL <br /> U ❑PIPING LEAK ❑STEEL E3 FIBERGLASS <br /> 0 <br /> OTHER (SPECIFY) ❑OTHER ®UNKNOWN []OTHER <br /> _ _ <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED ENED KNOWN WELLS <br /> YES NO THREATENED UNKNOWN YES NO <br /> 0 ll PUBLIC DRINKING rr,, r� �^1 <br /> F AIR (VAPOR) ❑ ❑ IJ WATER u FJ `' ❑ <br /> VSOIL(VADOSE ZONE) ❑ 0 ❑ ❑ PRIVATE DRINKING CD I] ❑ ❑ �_ <br /> W - GROUNDWATER 12 El EDWATER <br /> W SURFACE WATER OR STORM DRAIN ❑ Q ❑ ❑ INDUSTRIAL ❑ _ ❑ ❑ = <br /> OF BUILDING OR UTILITY VAULT ❑ � ❑ ❑ AGRICULTURAL ❑ Q ❑ ❑ <br /> , OTHER (SPECIFY) �� ❑ CD1:1❑ OTHER(SPECIFY) <br /> 0 ❑ ❑ ❑ <br /> N <br /> YI GROUNDWATER BASIN NAME <br /> C <br /> UNKNOWN <br /> COMMENTS: �yELL.S TEST E•D SilO:U�O <br /> w NO J,*^j TA Al 1^1A <br /> x <br /> F <br /> O <br /> u Mac oe uo/sei <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED . <br />