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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV FOR LOCAL AGENCY USE ONLY - <br /> REPORT FRED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ VES NO ❑YES REPORTED THIS INFORMATION TOICIALS PURSUANT TO SECTION 25180,7 OF <br /> REPORTDATE 9 CASES THE HEALTH AND SAFTY CCDE�I <br /> UM M l Y SIGNED `DATE <br /> NAME OFI/ L4'itm REPORT (HONE Jw wu SIGNATURE <br /> L <br /> a W l• 17 R spif, <br /> 0 REP ENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME // J <br /> ¢O LOCAL AGENCY ❑ OTHER OA-Q- LH/ �In 6 ILC � u rI CS <br /> 6 <br /> ADDRESS w/N��/�[ ! <br /> I V , •/o 1 SIY�__',! HATE / �W <br /> NAME yy /� CONTTAAg�T/PJERSON ,/ PHONE /[ <br /> �1?l12 I D UNKNOWN <br /> 24 <br /> 04A14 "��j I v_ <br /> yADDRESS <br /> CITY <br /> FACILMYNAME( ;MUCARLE) OPERATOR <br /> ''JJIfA Gifo �� Y <br /> ADDRESS U W ,,j ' '• E <br /> WY ZIP <br /> n <br /> CROSS STREET TYPE OF AREA ❑ MERCVLL❑WDUSTRIAL❑RURAL TYPEOFBUSINESS ❑ RETAIL FUEISTATION <br /> rvV ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w S �o tw �a. (L6 ie- 1 clo�ydP=3�/ <br /> w,µ� REGIONAL BOARD PHONE <br /> a RW s-7 Y <br /> (1) NAME OUANTRY LOST(GALLONS) <br /> P.. c le a An UKKNOWN <br /> g (2) <br /> m ❑ UKKNoWN <br /> i DATE DIVE D c' F7 ❑ RFACE MONfR7RNG ❑ NUISANCECONDITIONS <br /> w <br /> M M V <br /> D D v v ❑ KK TEST TAM(REMOVALOTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a ❑ UNKNOWNElREMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> M¢ M M D D Y V <br /> HASDISC RGE BEEN STOPPED? /f( I �r ❑ REPAIRTANK E::] REPAIRPPNG ❑ CHANGE PROCEDURE <br /> -O YES E] NO FYES.DATE YM Zu ZD • D rD v ❑ OTHER <br /> u� SOURCE OF DISCHARGE TIWKBjONLVA:APACITY MATERIAL CAUSES) / <br /> ❑ TANK LEAK UKKNOWN / J o o 0 CAL. ❑ FIBERGLASS ❑ OVERFILL �iF�FALURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION UKKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w <br /> :Z <br /> EONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECKON=ONLY <br /> i ❑ SITE INVESTIGATKIN IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> SH ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Z� ❑ CONTAINMENT 13ARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NOACTIONREOUIRED(NN ❑ OTHER(01) <br /> 2 — h dr.L ro u ,tea{ 4toLd# !So Ge iso. ryK Gcs <br /> cit5c500*10 ,fl- GPS L be, /zecC v defrCrsrsr.•�re <br /> �LGt z.rG lii1G�1 P.�4fsw�OF dd!? fCtIA& fzw/ s <br /> IMD06IM11 <br />