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it <br />UNDERGROUND STORAGE TANK.UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EM; S �QR LOCAL AGENCY USE ONLY = <br />i }IEREBi CERTIFY TiiA7 I AM A p${fYATEI? GOViNI�ll&NT EMPli3Y AF�q Ff i HAYS r <br />REPORT BEEN FIFD"? ; <br />YES YEs R&PORTEEi.TFIIS �iFORMATION TO.:OCH OFF[C(ALS PElRSl7ANT'i0 SECTlf7N 2*i1B>37 #; <br />EAiTAND <br />A <br />REPORTOATE CE <br />SE ".. <br />YM <br />M <br />NAME OF INDIVIDUAL FILING REPORT PHONE . SIGIIA RE" <br />(7,m)- <br />REPRESENTING Cl OWNEMPERATOR Q " REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />tOCALAGENCY E] OTHER <br />i <br />cc <br />ADDRESS <br />r(vd t r4zTr e : SATE <br />NAME <br />CONTACT PERSON <br />PHONE <br />❑ UNKNOWN <br />(720q),9119-1$ 21 <br />i <br />cc <br />ADDRESS �r. <br />reE/Lfool kr✓ ' � z off <br />-2,910 GJ. ATE zip <br />FACILITY NAME (IF APPLICABLE)OPE�R^ATOR <br />PHONE <br />L65 Loop -r <br />CX (moo qw-4l ZI <br />ADDRESS ..- y gS Zd <br />ZIP <br />y <br />CROSS STREET <br />TYPE OF AREA D660MMERCIAL EjINDUSTRIAL Q RURAL <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />rx jl4Oti/r v <br />E::] RESIDENTIAL OTHER <br />Q FARM OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE . <br />w <br />(209) 3,131 <br />w w <br />REGIONAL BOARD <br />PHONE <br />cL <br />� 4 <br />i../ 1 I t ( c 13 <br />\ q1 <br />co <br />f�I NAME QUANTITY LOST (GALLONS)' <br />w p <br />( UNKNOWN <br />0 <br />(2) <br />n <br />S QC I (KUNKNOWN <br />i <br />OATS DISCOVERED <br />/q HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br />6 TANK <br />Y Y TEST TANK REMOVAL OTHER <br />DATE DISCHARGE BEGAN - METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />}Q <br />_ P; -,UNKNOWN REMOVECNTENTS REPLACE TANK CLOSE TANK <br />p <br />HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK - REPAIR PIPING CHANGE PROCEDURE <br />p,. <br />YES [�] NO IF YES, DATEv' OTHER <br />r <br />SOURCE OF DISCHARGE TANKS OCAUSS) <br />MATERIALIBERGLFISSLYcAPACITY <br />E <br />N <br />7 <br />F7 TANK LEAK �J� UNKNOWN -2QQ� F <br />GpL• <br />iF�.. - .-- 0 O OVERFILL RUPTUREfFAILUpE <br />cc <br />PIPING LEAK AGE YRS STEEL CORROSION UNKNOWN <br />8, <br />OTHER.0 NKNOWN Ej OTHER SPILL 0 OTHER <br />w w <br />CHECK ONE ONLY . <br />a <br />UNDETERMINED LA SOIL ONLY GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECK ONE ONLY <br />2 <br />¢t4 <br />cr, <br />--SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS 0 SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />, <br />L) N <br />NO ACTION TAKEN a POST CLEANUP MONITORING IN PROGRESS D NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />0 4 O <br />CAP SETS (CD) EXCAVATE & DISPOSE (ED) a REMOVE FREE PRODUCT IFP) ENHANCED SIO DEGRADATION (IT) <br />c� <br />CONTAINMENT BARRIER (C8) a EXCAVATE & TREAT (ET) PUMP & TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />TREATMENT AT HOOKUP (HU) NO ACTK)N REOUIRED (NA) OTHER IOT) . <br />�uiz7n -� 5i-rE 1955C---5A4Fln.1T Wr.L <br />or E -Ir -c vT >�' COn�TI?M�Nr47ian/, f35 ��4U1lz�D 8Y Tti�- APP+�o�e-i./tTE_ A4�Ncy <br />8 <br />HSC 45 (4187) <br />n <br />