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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) ! CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMEP49NCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES /NO REPORT BEEN FILED? pp�YES ❑ NO HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> I� REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25+80.7 OF. <br /> REPORT DATE CASE# THE HEALTH AND SAFTY CODE ^S <br /> In <br /> UM M 2- 2-.111 Y Y SKiNE DATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> 12 REPRESENTING ❑ f� F-1OWR/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> y LOCAL AGENCY ❑ OTHER SK1 pff <br /> w <br /> ADDRESS �/ <br /> 100, u" 7 E r DRY STATE (7520 ZIP <br /> w NAME CONTACTPERB�+ PHONE <br /> Dirk ell d E w, Co ❑ mm" fL (.tet ) `/62-769G <br /> S y ADDRESS <br /> F 1 SKEET CITYCA STATE D5­ OP <br /> FACILITY NAME IFAPPLICABLE} 1 OPERATOR PHONE <br /> Cork Well , mPN� Ca ?I;n C'a ) 77 H <br /> ADDRESS <br /> 14 202Y E 44, LAb9n SAa CRY <br /> J tiJ CQ NTY OS' P <br /> m CROSSSTREET <br /> 0LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> z16W - <br /> i' S C' N c2� )SKsf 3yyo <br /> w REGIONAL BOARD PHONE <br /> a <br /> y (t) NAME QUANTITY LOST(GALLONS) <br /> a <br /> a> IZUNKNOWN <br /> (2) <br /> ❑ UNKNOWN <br /> i DATTEDISJCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ED SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 6M �IST M0_.lD r Y ❑ TANKTEST [o TANKREMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Ml M DI DI YJ Yl ITY�/ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> Q HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK <br /> ❑ REPAIR PIP IN ❑ CHANGEPROCEDURE <br /> o YES ❑ NO FYES.DATE 01 MI DI Di YJ Y t OTHER Ia^�j2 <br /> G SOURCEOF DISCHARGE CAUSE(S) <br /> ¢� ❑ TANK LEAK UNKNOWN ❑ OVERFLLn TiUPTURE(FAILURE ❑ SPILL <br /> O ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION 'I'I//—yy��T(/UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER. (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> Z ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMNTED ❑ POLLUTION CHARACTERIZATION (� <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS �J <br /> O <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY 1 <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Ia:evusanoe Mq <br /> w ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(El) ❑ "UMP&TREAT GROUNDWATER(GID ❑ REPLACE SUPPLY IRS) <br /> ❑ CONTAINMENT BARRIER(CEI) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENTAT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑Q�V�AJCUUM EXTRACT(VE) E:] OjT�H,EfRR(OID L- <br /> have <br /> 3 <br /> GAd4er SJ�t9'S Eij 1 »" <br /> N9COSI,,,99I <br />