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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGE I�EY SERVICES <br />REPORT BEEN FILED ? <br />FOR LOCAL AGENCY USE ONLY <br />THEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT .I HAVE <br />❑ YES NO YES ❑ NO <br />PURSUANT TQ. SECTION OF <br />REPORTED THIS. INFORMATION TO LOCAL:OFFICIALS 25180.7 <br />THEH THANDSAFTY <br />RIEPOR"T�/jD,ATE <br />ASEX <br />SIO E DATE . :I <br />l M !/ M D Y <br />NAME OF INDIVI UAL FILING RE ORT <br />PHONE <br />SIGNATU <br />(toy) II&F 3gvD <br />KAe <br />co <br />0 <br />REPRESE I ❑ ❑ �'COMPANYORACENCYNAME <br />O NERIOPERATOR REGIONAL BOARD <br />m <br />a <br />LOCALAGENCY ❑ OTHER <br />L/ <br />Q <br />ADDRESS <br />CTTV STATE ZIP <br />NAME <br />CONTACT PERSON <br />PHONE <br />❑ UNKNOWN <br />Qa <br />Lli <br />ADDRESS / 0 <br />Las <br />STREET CITY STATE <br />FACI ITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />JCS/ <br />(�� �ZZ <br />o <br />vol�_ <br />ADDRESS <br />&7eplAJ .51,971f J019 <br />STREET CffV COUNTY ap <br />yCROSS <br />STREET <br />TYPE OF AREA ❑ COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESSRETAIL FUEL STATION <br />RESIDENTIAL ❑OTHER <br />❑ FARM ❑OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />W <br />II <br />C <br />W Lu <br />REGIONAL BOARD <br />PHONE <br />a <br />/ <br />(I) NAME QUANTITY LOST (GALLONS) <br />O� <br />! /���S ❑ UNKNOWN <br />V <br />(2) <br />nj <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />Lij <br />Mp' M o�D .1 Y <br />❑ TANK TEST ❑ TANK REMOVAL E2 --OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />Q <br />UNKNOWN <br />M M D D V Y <br />❑ REMOVE CONTENTS E] REPLACE TANK ❑ CLOSE TANK <br />w <br />> <br />REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />p <br />Q YES ❑ NO IF YES, DATE <br />❑ OTHER <br />Y <br />w <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK ❑ UNKNOWN <br />GAL. ❑ FIBERGLASS <br />❑ OVERFILL ❑ RUPTUREIFAILURE <br />E PPING LEAK <br />AGE YRS ❑ STEEL <br />❑ CORROSION ❑ UNKNOWN <br />E] OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL OTHER _ 11 �,JL>VL <br />w w <br />CHECK ONE ONLY <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECK ONE ONLY <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) [2 CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />cr <br />U y <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DE AILS) <br />z <br />50 <br />F-]CAPSITE (CD) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />w❑ <br />CONTAINMENT BARRIER (CB) F -] EXCAVATE& TREAT (ET) ❑ PUMP &TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />cr <br />TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA)❑� OTHER (OT) <br />�!❑ ohe&, %Z) b6FF/A%G-9�- <br />A,,-r K& OF <br />8 <br />