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iAlk 'Aft _-1 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY - HAS STATE $TATE TANK ID ir ❑ YES 111 NO REPORT BEEN FILED ? E:] YESCE OF NCY SE VICO1/44/1 tlle ES , / REPORT DATE ��(/ LOCAL CASE M REGIONAL BOARD CASE#' US EPA ID k el' Q Y NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT E w REPRESENTING F-] LOCALAGENCY ❑ OTHER COMPANY OR AGENCY NAME 'x X OWNER/OPERATOR ❑ REGIONAL BOARD O ir W ADDS Dvx �i� SOS �� C 9oa�� STREET C 7Y STATE ZI ( >- NAMES CONTACT PERSON G ONE 0< / /©.6j1- v� UNKNOWN a a w ADDRESS /by W J / V e R E G CITY It m ATE ZIP O FACILITY NAME (IF APPLICABLE) � Off OPERATOR J � PHONE ' IL 07f O ADDRESS ,�T��✓//��'/ /�j� / V/� g!✓��/ 37� 5 R gl(� �(/P CITr/ COUNTY ZIP CROSS STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL TYPE OF BUSINESS RETAIL FUEL STATION [:]RESIDENTIAL ❑RURAL ❑OTHER ❑UNKNOWN [—]OTHER LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE !` 7 O ) eA 6 z N z w REGIONAL BOARD D w001, Z, l� ) 6 7_ a a TSCD f w CAS X (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) O <j (1) I UNKNOW m O M> Z L (2) 1 1 1 1 1 1 1 1 UNKNOW DATE DISCOVEREDHOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING l H I �, �, ROUTINE MONITORING ❑ REMOVAL TANK C-I NUISANCE CON DI TIONi OTHER: ,_ K Z Ill DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) >f Ow D D Y YJ UNKNOWN REMOVE CONTENTS C1 REPLACE TANK CLOSE TANK m HAS DISCHARGE BEEN STOPPED? �< - 41 �;REPAIR TANK LI REPAIR PIPING L CHANGE PROCEDURES YES NO IF YES, DATE M M D Y *Y J OTHER _ O,/U CE(S) OF DISCHARGE TANKS ONLY/CAPACITV !/ GAL CAUSE(S) D 11!)TANK LEAK I❑ UNKNOWN f.q• l_J OVERFILL ❑CORROSION < 7� AGE I�T YRS. L❑ UNKNOWN U U [-]PIPING LEAK MATERIAL RUPTURE/FAILURE E]SPILL STEEL ❑FIBERGLASS MOTHER (SPECIFY) OTHER UNKNOWN [_JOTHER RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- N- YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS F AIR (VAPOR) ❑ El 1_1 PUBLIC DRINKING Ll I--I �-� W SOIL (VADOSE ZONE)11 El a CI WATER - L PRIVATE DRINKING f-1 E f�l w GROUNDWATER ❑ O L1 WATER L__1 I_J 1-_J u T SURFACE WATER OR STORM DRAIN El ❑ ❑ W 0 � INDUSTRIAL I❑ ❑ R~< BUILDING OR UTILITY VAULT Ll � ❑ E] AGRICULTURAL ❑ n ❑ � OTHER (SPECIFY) C7 ❑ ❑ ❑ OTHER(SPECIFY) ❑ ❑ ❑ GROUNDWATER BASIN NAME UNKNOWN COMMENTS: + F- F- 0 O U COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED H>C 05 (10/e5)