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UNDERGROUND STORAGE . .NK UNAUTHORIZED RELEASE (LEAW—,"-ONTAMINATION SITE REPORT <br /> ENF_RGE NCI HAS STATE OFFICE OF EMERGENCY SERVICES STATE TANK ID %. <br /> nn <br /> [Dow <br /> YES /NO REPORT BEEN FILED? 0 YES NO <br /> RbPOR„I DATE OLOCAL CASE n REGIONAL BOARD CASE u <br /> M M D D Y 17 <br /> I <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> JC - fir c Za`i 4b ' 3 1 <br /> DREPRESENTING L�- LOCAL AGENCY a OTHER COMPANY OR AGENCY NAME <br /> OU <br /> OWNER/OPERATOR REGIONAL BOARD J50(AQU.titJ <br /> aADDRESS <br /> a �4 5 rJ .JoAt�w,,� Sn vr� - ci SZ <br /> STREET CITY STATE ZIP <br /> I F NAME <br /> CONTACT PERSON PHONE <br /> UNKNOWN UJ "S - INr1L^ ( �"i <br /> SZQ C�h2/)� u. t\, : r <br /> O 2 <br /> w �'0/ <br /> aADDRESS `/ IC�•.•� <br /> LU J �..J��� T^ d� <br /> irm STREET CITY STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> < ADDRESS 3y�c k(_ -a`Vr N\ <br /> STREET ITY COUNTY <br /> 1J ZIP / <br /> J <br /> H CROSS ST ET `\yl, TYPE OF AREA [ COMMERCIAL D INDUSTRIAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> I/I E]RESIDENTIAL RURAL OTHER [_ ]UNKNOWN 0 OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT P RSON PHONE <br /> LD <br /> N spio SbA Qw►J ti t ui 1- i `� �� c�C�rr�1�ti�`c c 2 0'( � 4�`v'3A4 <br /> Z W REGIONAL BOARD <br /> wZ <br /> ww <br /> a a TSCD <br /> w CAS a (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> Z w (�) -Q UNKNOW <br /> ,j <br /> NO <br /> m J <br /> ,�- (2) n UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED U INVENTO Y CONTROL [SUBSURFACE MONITORING <br /> ' Z Y $, L ROUTINE MONITORING �EMOVAL L] NUISANCE CONDITIONS r OTHER: <br /> yF M M D D Y <br /> ww DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> OF MI MI D DI YJ Y UNKNOWN Q REMOVE CONTENTS REPLACE TANK n CLOSE TANK <br /> m HAS DISCHARGE BEEN STOPPED? `J REPAIR TANK U REPAIR PIPING 0 CHANGE PROCEDURES <br /> a <br /> YES ONO IF YES, DATE I MI Ml D D Y Y ❑OTHER <br /> w SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY GAL CAUSE(S) <br /> '^ TANK LEAK ,UNKNOWN U OVERFILL CORROSION <br /> a AGE YRS. O UNKNOWN <br /> W 0PIPING LEAK MATERIAL Lj RUPTURE/FAILURE E]SPILL <br /> ¢ F-1STEEL �� FIBERGLASS <br /> ONOTHER (SPECIFY) OTHER E?rUNKNOWN OOTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- - <br /> YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS <br /> O <br /> w PUBLIC DRINKING <br /> I- AIR (VAPOR) D El Cl I_ 0 1:1 n <br /> W <br /> L <br /> SOIL (VADOSE ZONE) _ WATER <br /> i. � PRIVATE DRINKING f-1 <br /> w GROUNDWATER D Erl, O WATER L-J LJ L10 <br /> W R SURFACE WATER OR STORM DRAIN 0 u El INDUSTRIAL Fj O El O <br /> ¢~ BUILDING OR UTILITY VAULT I_� 0 AGRICULTURALEl 0 <br /> pa OTHER (SPECIFY) EI L_.__1 O O OTHER(SPECIFY) 0 D 0 O <br /> w <br /> r GROUNDWATER BASIN NAME <br /> n U N K NOW N. <br /> COMMENTS: 61-4'C— WEU _ I?� 1�-�6 �d�N�-µ•VDJ <br /> n"> tLlxl'T�'sC� L Tt,�—; or Ciz 'rY'rN lNLky�O� I t.j sc>�lr � l,sgL <br /> f <br /> 0 <br /> D <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED HSC 05 (I0/85) <br />