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UNDERGROUND STORAGE UNAUTHORIZED RELEASE (LEAK) TAMINAT E REPORT EMERGENY HAS STATE OFFICE OF EMERGENCY SE ICES STATE TANK ID A F-1YESNO REPORT BEEN FILED? ❑ YES NO REPORT)DATE LOCAL CASE # REGIONAL BOARD CASE # US EPA ID# 0 OM G4D f D Y UY 1�u G 2 9. 199 NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE w REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPP�c R AG CY NAME OOWNER/OPERATOR ❑ REGIONAL BOARD % �� J a ADDRESS L 3�u 7 X,n r ��,� Vis' fe�cx/�ofY STREET CITY STATE ZIP I FY NAME /J CONTACT PERSON PHON/E! (� 3 OQ0. t// ❑ UNKNOWN m w ADDRESS O:m rogd� ofy c \C` T CITY STATE (G / Z1 FACILITY NAME (IF APP CABLE) OPERATOR — r L COl G.,. PHONE J Q ADDRESS T JO � STREET CITY�/�Cf f/ Lrl yl S �i J F�Y/4 �V COUNTYT; ZIP F C/F}OSS ST EET TYPE OF AREA `� COMMERCIAL ❑INDUSTRIAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION `n �jn�/ciC♦ E:]RESIDENTIAL ❑RURAL ❑OTHER CJ UNKNOWN OTHER LOCAL AGE AGENCY NAME CONTACT PERSON- PHONE Z ✓a"l 'l li d /Y'/ ��- ✓�i� ~ Z W REGIONAL B RD WU WW as TSCD w CAS # (ATTACH EXTRA SHEET IF NCEDED) NAM QUANTITY LOST (GALLONS) UD a> (1) UNKNOW J nO m> m (2) n UNKNOW DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING >-F- M M D D y y [:] ROUTINE MONITORING REMOVAL ❑TANK NUISANCE CONDITIONS ❑ OTHER: IrZ ww DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT AP LY) UW M M D D Y Y UNKNOWN ❑ REMOVE CONTENTS E] REPLACE TANK CLOSE TANK m HAS DISCHARGE BEEN STOPPED? L]REPAIR TANK [—]REPAIR PIPING ❑CHANGE PROCEDURES a YES NO IF YES, DATE M M D D Y Y E:]OTHER w URCE(S) OF DISCHARGE TANKS ONLY/CAPACITY 706jS0 GAL CAUSE(S) rn ❑TANK LEAKUNKNOWN EDOVERFILL ❑CORROSION I ' ' ¢ 14AGE W YRS. ❑ UNKNOWN U W F-1PIPINGLEAK MATERIAL ❑RUPTURE/FAILURE [:]SPILL U STEEL ❑ FIBERGLASS m D N ❑OTHER (SPECIFY) [:]OTHER W UNKNOWN ❑OTHER RESOURCES AFFECTED YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTEDTHREAT- O YES NO ENED KNOWN WELLS UAIR (VAPOR) E] Ey ElE] WATER DRINKING ❑ ❑ —_— WSOIL (VADOSE ZONE) ElPRIVATE DRINKING U. GROUNDWATER ❑ ❑ FVr ❑ WATER WSURFACE WATER OR STORM DRAIN ❑ ❑ ❑ INDUSTRIAL ❑ ❑ ❑ ¢F¢ BUILDING OR UTILITY VAULT X , ❑ ❑ ❑ AGRICULTURAL El El EY =OOTHER El El El El OTHER(SPECIFY) ❑ ❑ ❑ L❑P W m GROUNDWATER BASIN NAME UNKNOWN COMMENTS: H 2 W E f O U COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED 143C 05 (10/e5)