Laserfiche WebLink
UNDERGROUND STORAGE TAN UNAUTHORIZED RELEASE (LEAK)I60-NTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF,EMERGENCY SE VICES STATE TANK ID R <br /> YES T�f1 NO REPORT BEEN FILEDT YES IC <br /> NO jm�Mld <br /> REPORT DATE LOCAL CASE u REGIONAL BOARO CASE # US EPA ID # <br /> V� V Y <br /> NAME OF INDIVIDUAL FILING REPORT <br /> m '-- <br /> PHONE SIGNAT E <br /> ECOREP LOCAL AGENCYMPANY OR AGENCY NAME <br /> LOARp OWNER/OPERATOR REGIONAL <br /> I-ADDF�``((fJS ��� // \ �"�i�� I / �V v 4✓ / OY�� <br /> STREET C Y <br /> TATE ZIF <br /> I > NAME CONTACT PERSON PHONE L/ <br /> za Mo/G & O� UNKNOWN C ou <br /> p <br /> Ld aW ADDRESS iKr ��C/ O�11r�3 , r • /' - YY% ATE - ZIP <br /> x m V "ST'ft EE rCITY <br /> O FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> 4 ADDRESS <br /> 0 Y�D/(R} /�/] <br /> -3 75" SJR E /Y A�'/ 0 NST Y,• ./ZIP <br /> w CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> �^ LJ RESIDENTIAL a RURAL Q OTHER Lj UNKNOWN D OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zw R GIONAL BOARD <br /> �W <br /> a< TSCD <br /> CAS # (ATTACH EXTRA SHEET IF NEEDED) NAME ,/y QUANTITY LOST (GALLONS) <br /> 00 UNKNOW <br /> I-J <br /> wo <br /> M> <br /> —[:] UNKNOWN <br /> N= (2) <br /> DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL SUBSURFACE MONITORING <br /> yF Y Y ROUTINE MONITORING REMOVAL TANK U NUISANCE CONDITION; OTHER: <br /> WZ <br /> w DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> OWREMOVE CONTENTS f REPLACE TANK CLOSE TANK <br /> OF D D Y YI UNKNOWN L� <br /> �m HAS DISCHARGE BEEN 5TOPPEDT ]REPAIR TANK REPAIR PIPING L}CHANGE PROCEDURES <br /> q a [ ! <br /> YES NO IF YES, DATE M M p Y YLi OTHER . <br /> O CE(S) OF DISCHARGE TANKS ONLY/CAPACITY 0 GAL CAUSE(S) <br /> TANK LEAK IED UNKNOWN ��G�� L1OVERFILL CORROSION <br /> q AGE I !Tr YRS. UNKNOWN <br /> w 0 PIPING LEAK MATERIAL iJ RUPTURE/FAILURE [:J SPILL <br /> USTEEL FIBERGLASS <br /> Ir 156 <br /> F:l OTHER (SPECIFY) ❑OTHER UNKNOWN O OTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- <br /> UN- UF <br /> YES NO THREATENED UNKNOWN YES NO ENEDKNOWN WELLS <br /> Ir- AIR (VAPOR) Q El I_� PUBLIC DRINKING <br /> w SOIL (VADOSE ZONE) WATER <br /> U. 0 0 �� PRIVATE PRINKING <br /> U. GROUNDWATER WATER L J Jlq� <br /> SURFACE WATER OR STORM DRAINFE Q INDUSTRIAL <br /> ff4 BUILDING OR UTILITY VAULT AGRICULTURAL <br /> m OTHER (SPECIFY) El El LA El OTHER(SPECI FY) <br /> O <br /> 4! <br /> x GROUNDWATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS: ur <br /> � T+�-ClTJC� ©C—iSE F.l 2P�j (�16(L ro .�A�+ l)198'x, 1 u J�SaT G—Pc'�lDYJ O!�—Cv0!FJCv. <br /> Z <br /> W <br /> 0 <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED r15C 05 (l0/85) <br />