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M_ I I ml <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGE Y HAS STATE OFFICE OF EMERGENCY SERVICES <br />'.FOR LOCALAGENCY USE ONLY <br />REPORT BEEN FILED ? ��� <br />ES NO YES "" <br />1 HEREI3Y CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT .EMPLOYEE: AND THAT) HAVE <br />I� I <br />REPORTED THIS: INFORMATION: TO LOCA OFFICIA RSILIANT TO;:SECTION 25180,1 OF <br />THE HEALTH AND SAFtY CODE .> <br />REPORT DATE <br />casE x <br />vM �D `v (v <br />;SIGNED : DATE.:..' <br />M <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE IV <br />w <br />REPRESENTINGOWNERIOPERATOR REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />a <br />LOCAL AGENCY OTHER <br />0 at � 4LLI L v 1 S IJ <br />cc <br />ADDRESS <br />1 � PV t of �O � STREET Ju c7%, -SO ✓\JIDA L"l ✓ CITY -57j�� STATE Q <br />/ S Z2 <br />J <br />NAME <br />OINNTTACT PERSON <br />PHONE <br />co <br />z¢ <br />, 1 <br />V r G ✓1 S O/ T E] UNKNOWN <br />' <br />• c r jC ` L/ i YJ <br />(Z�Y j SZZ- �yFi Z <br />R a <br />ADDRESSLij2_ <br />l/^) / 7 �1 ZC. <br />55 <br />v U� �/ <br />STREET-_2 <br />CRVS* C V' / STATE ` f Zlp�� <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />o <br />V 1 y� c ✓i $ O ,/' L <br />( j <br />ADDRESS <br />CL a r / Uv a <br />Li <br />STREET CfTy COUNTY G <br />y <br />CROSS STREET <br />TYPE OF AREA J COMM RCIAL F--] INDUSTRIAL RURAL <br />TYPE OF BUSINESS [::] RETAIL FUEL STATION <br />"4�e -5 `j <br />a RESIDENTIAL F --]OTHER <br />FARM 0 OTHER <br />W <br />LOCAL AGENCY AGENCY NAME <br />t— ��� <br />CONTACT PERSON <br />�G <br />PHONE <br />Sc a v,� O <br />�� 1 TJ <br />(zoo!) y6 ,--3ySY <br />w <br />REGIONAL BOARD <br />PHONE <br />L'V LR 0&C-5 <br />36/-- 5726 <br />w� <br />(�) NAME QUANTITY LOST (GALLONS) <br />J <br />-so \ Q UNKNOWN <br />N <br />(2) <br />�l�e•�� ��� <br />/ L &7 If --I UNKNOWN <br />Z <br />w <br />DATE DISCOVERED <br />3 <br />HOW DISCOVERED I VENTORY NTROL E] SUBSURFACE MONITORIN a NUISANCE CONDITIONS <br />�� <br />M M D D Y V <br />/ <br />TANK TEST O TANK REMOVAL OTHER $ v i/✓ C.G 1 Vj$ G T 7d <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />W <br />M M D DI Yl Yl UNKNOWN <br />REMOVE CONTENTS E::] REPLACE TANK CLOSE TANK <br />p <br />pYES <br />HAS DISCHARGE BEEN STOPPED 7 <br />��,R;EPAIR TANK R PAIR PIPING El CHANGE PROCEDURE <br />� NO IF YES, DATE M M .1 .1 y y <br />U OTHER eX (q �/, j ey12k,*j j� q 90,'/ <br />LLJ <br />SOURCE OF DISCHARGE <br />TANK LEAK UNKNOWN <br />TANKS ONLY/CAPACITY MATERIAL <br />SCM �� S ODa GAL. FIBERGLASS <br />CAUSE(S) <br />E] OVERFILL RUPTURE/FAILURE <br />0 <br />E-1PIPING LEAK <br />AGE r� YRS STEEL <br />CORROSION JNKNOWN <br />$ <br />0 OTHER <br />2rUNKNOWN [�J—OTHER <br />SPILL L:j OTHER <br />w w <br />on <br />CHECK ONE ONLY <br />UNDETERMINED SOILONLY GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />N <br />CHECK ON NLY <br />Z <br />cc a <br />SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS O SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />¢p <br />U N <br />F—] NO ACTION TAKEN [�] POST CLEANUP MONITORING IN PROGRESS E:] NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />z <br />00 <br />F—] CAP SITE (CD) F7 EXCAVATE & DISPOSE (ED) REMOVE FREE PRODUCT (FP) ENHANCED BIO DEGRADATION (IT) <br />w <br />O CONTAINMENT BARRIER (CB) EXCAVATE & TREAT (ET) E:] PUMP & TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />E] TREATMENT ATHOOKUP (HU) [::] NO ACTION REQUIRED (NA) OTHER(OT) <br />,Q,? env,vo,71,lell7 iG✓t'�' Cm/J /'7iit)4 a/1. �i (n/!,.$ elLeaIla O' <br />z <br />/^A.SSCSS/✓!il <br />4/�p'n�,y gtr9 f�..{I�• /_„'' f'ljp� a s 5eS-5;- ,o l � �v�`�� pc /JGceSS-7 /V <br />0#7 ” 'i V �� n � ( A7 iil 9 �% <br />/ <br />HSC 05 (4M7) <br />