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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FORLOCALAGENCY USE ONLY <br /> REPORT BEEN FLED? 1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT t HAVE <br /> ❑VES NO ED YES �',,ND REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECT <br /> pN 25180.1 OF <br /> CASES THE HEALTH AND SAM CODE. <br /> REPORTQDATE Q <br /> QM Q. O 6 { r 6 r SIGNED MTE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> > MKA�C 195) 9228-33oa <br /> o REPRESENTING ��OWIEWOPEMTOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 E] LOCAL AGENCY [:] OTHER <br /> 0 <br /> ADDRESS <br /> A7A T /ja_vA SA�/tr9 e..ATo !.4 Cl SV34 <br /> 1433 At. STATE zip <br /> NAME CONTACT PERSON PHONE <br /> y£i A4to P.rvwLas p ❑UNKNOWN 64-r- N 1ia.s /916' <br /> k u S&&&&� ADDRESpp bog 6/z $AKS SKas� Csi CS/E! <br /> cm srA*E r° <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> A441 in/ C4 A2-TER uA� .STcxrc-rp J SM/ JCmQw"f If 206 <br /> RE <br /> STREITm Krrmp <br /> yCROSSSTREET TYPE OF AREe�COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> `1 [.OLAJ [:]RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w SM1 AJ CwN T MI A NFLf2nJA �) -3454- <br /> 2 REGIONAL BOARD <br /> PHONE <br /> CE J Tlz+t� LI�iL Y" eE�wK� EL-Izwsa- w `Tto Ere- ('TI6) LS'S- 3cco <br /> (�) NAME OUANTRY LOST(GALLONS) <br /> N qq <br /> U"L.EAPGC> C A',SOL.w UNKNOWN <br /> m <br /> _ t EAbED G ASoL-LSI E UNKNOWN <br /> r DATEDISCOVEREDHOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUSSURFACEMONITORNG E:] NUISANCE CONDITIONS <br /> k6. ZM 0. 7 D 1, 6 r ❑ TANKTEST �TANKREMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> - MI MI DI DI VI Y ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> 5> HAS LOISCHARGE BEEN STOPPED? p `I❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> o VES ❑ NO FYES.OATE � 0. 70 /r Gr .i�`A,OTHER TSVIVC- MA04AL- /PLpIWG REAxwokL <br /> yi SOURCE OF DISCHARGE TANKS ONLYADAPACITY I_-._JAATERIAL CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN (A VGK,.OV FIBERGLASS ❑ OVERFILL ❑ RUPTUREJFAILURE <br /> ❑ PI'RING LEAK AGE Z I YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> CHECKONEONLY <br /> t3 ❑ UNDETERMINED ❑ SOILONLV GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Fg CHECKONE ONLY <br /> gg Ki ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS❑ SK3NED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> DN ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANLIPALTERNATNES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> S ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) E] REMOVE FREE PRODUCT(FP) E] ENHANCED BID DEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) EXCAVATE A TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REWIRED INA) OTHER(OT) SVE <br /> ¢ FUEL- U5TS R -mOvFp : 2 GooO GAL, j 1 Qpti� 6AL,uo J <br /> a STEF_L_ I.I s-rAUA..64tb- LA" m-roTs 1 101j 000 NA A r1(SECC NLACA <br /> S LAJ5-m"sA 1"o. <br /> $ VAGL.A-r Y NO LoNG62 ILJ OPEaATIO <br /> JUOTT J11&%)�,- 10?6 <br />