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i �Cj _ ,—I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> f' EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FQR LQG 4L;4GENCY.USE ONLY. <br /> REPORT BEEN FILED? <br /> 71 YES NO ❑YES ❑ ND 1`HEREEIY CERTIFY THAT:f AMA DESIGNATED:GOVERNMENT EMPLOYEE AND THAT l HlSVc' <br /> REPORTED THIS INFOR040bN TO::OCAL OFFICI pURgUAN3 TO SEGTIpAI 251gp 7'OF <br /> REPDIRTDATE `2] /+�J ]G� CASEA THEH�ALTHA DSAFTY .. <br /> E [ M Jp� V D FYI I Y <br /> SIGNED s <br /> NAME OF INDIVIDUAL FILING REPORT fuTE <br /> PHONE SIGNATURE <br /> { <br /> REPRESENTING ❑ OWNERJOPERATOR ❑ RE IONALBOARp COMPANY ORAGENCY NAME <br /> v(! <br /> w LOCAL AGENCY OTHER `� <br /> ADDRESS <br /> L ! STREETLu �7OC� C•� } �J ��/V / yi <br /> CITY ! STATE / € <br /> NAME ft:0 <br /> �Q CONTACT PERSON PHONE�j� 2 21A �j f <br /> fl ADDRESS � NWN /GL.�G/� I',J F ! 1 S�� r! �7✓ <br />,I mn. <br /> 4 C <br /> uj 4w) <br /> m' <br /> FACILITY NAME(IF APPLICABLE) OPERATOA CSTATE ZIP <br /> �� I PHONE <br /> 9 1 'IF46 JOA&RI/V cd-4 I (-,Eoq f� <br /> a ADDRESS <br /> clouNrf ZIP <br /> CROSS STREET TYPE OF AREA ❑ MMERCIAL ❑INDUSTRIAL ❑R11RAIL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> �f 0 0 RESIDENTIAL ❑OTHER �l p ❑ FARM ❑ OTHER <br /> p y LOCAL AGENCY ` AGENCY N�MF� J n �.• '] CONTACT PERSON PHONE [� <br /> w W +-4�f/1 �y- V ►7\f <br /> J REGIONAL BOARD !1 PHONE <br /> G v p, tv G C illi (9W)y'G/-s o <br /> y (1) NAME If QUANTITY LOST(GALLONS) <br /> O .. <br /> i �L} lei G rN UNKNOWN <br /> Z �` �•c. w� � c.�h j � <br /> F J <br /> ('L„ I <br /> N b ) <br /> m <br /> W ❑ UNKNOWN <br /> Z DATE DISCOVEREEJjD �//� HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDSTIONS <br /> Lu <br /> m Li t M /D D� % r q r ❑ TANK TEST TANK REMOVAL ❑ OTHER f <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Y UNKNOWN 0 REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> M m4 D D Y Y 1� <br /> O HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK <br /> E] REPAIR PIPING CHANGE PROCEDURE <br /> p YES ❑ NO IFYES.DATE M1 M aI DI Yl YJ ❑ OTHER <br /> ui SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL I I CAUSE(S) <br /> 4 ❑ TANK LEAK UNKNOWN ���a� 1 GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> PIPING LEAK AGE 1!9-7-7 YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN OTHER ❑ SPILL X] OTHER <br /> Lu w CHECK E ONLY <br /> d <br /> UNDETERMINED ❑ SOIL ONLY E:] GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHE ONr ONLY <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS'❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY)cc <br /> j <br /> a: Il <br /> rn _] NO ACTION TAKEN [:] POST CLEANUP MONITORING IN PROGRESS E::] NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES (' <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o zO ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMi AVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) �- <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE G TREAT(ET) PUMP,B TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) t' <br /> cc <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) OTHER <br /> Svr'L ✓'Gsui-'S re e4 f GorrfaAroma- �P�N <br /> ' r-� �� s <br /> o.Jed at t tr c }-pr,� +� a( I°►p, �j r ,� l /0 <br /> —7 _ g e` C <br /> k>2 82 Qi e SSe®�iFi G� fir/ "L i� G kVy"J�ee-A <br /> $ l f;l rei �E( .P/ �►'i-J 9/- o, /v i/9-/+'� _/�iG3 7 t7 GG%iee d b y' i <br /> �J r IJ <br /> eSC C6( [ <br /> i <br /> �F <br /> ' rF <br />