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IftP <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI FOR LOCAL AGENCY USE ONLY <br /> REPORTBEENFILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES NO ❑YES REPORTED THIS.INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASES THEHE AND SAFTY <br /> M D Y <br /> SIGNED I DATE <br /> AMEO INDIVIDUAL FILING REPORT PHONE /' SIGNA <br /> L. IO ") T6cp 3,LF(00p <br /> O CREPRESE ING ❑ OVINEWOPERATOR ❑ REGIONALBOARD COMPANYORAGENCY NAME ovAlT�/ <br /> � LOCALAGENCY ❑ OTHER <br /> a <br /> AGGRESS <br /> /loot e. Nq S. A✓e DRY lT <br /> arAre nP <br /> NAME CON <br /> PHONE <br /> B U NKNOWN <br /> y ADDRESS 9-,7,9/wsO(y <br /> CRV 8 ATE mp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> E712t X& <br /> ADDRESS ns� 6/„ <br /> ,3q c ( A,°T wi9y 7 W <br /> srReer cm ceuxry ap <br /> qCROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL R7URAL OF BUSINESS E::] RETAIL FUEL STATION <br /> x4v ❑RESIDENTIAL ❑OTHER ❑ FARM &�OTHER <br /> LOCALAGENCY AGENCY NAME �T CONTACTPERSON PHONE <br /> >Ev/ D6 i) (moi) (ail-3<< c <br /> REGIONAL BOARD /� PHONE <br /> G2ulQ Gordon/ <br /> p) NAME QUANTITY LOST(GALLONS) <br /> W <br /> ❑ UNKNOWN <br /> (a <br /> �- ❑ UNKNOWN <br /> b DATEDISCOVERED �j G HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACEMON[TORING ❑ NUISANCE OONUffXNJS <br /> M O D O v V ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> �IQ1pV/N REMOVE CONTENTS ❑ REPLACE TANK E] CLOSE TANK <br /> w M M 0 D Y V <br /> HAS DI BEENSTOPPED? G,' ❑I RREE.PAAIRTANK ❑ REPAIRPPWG ❑ CHANGEPROCEDURE <br /> p YES ❑ ND FYES,DATE D v /v L W� "R , <br /> yy SOURCE OF DISCHARGE TANKSONpL�V,CAPACITY MATERIAL CAUSE(S) <br /> 34 ❑ TANKLEAK O UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUFEiFAILURE <br /> ❑ PIPINGLEAK AGE YRS ❑ CORROSION E " NOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECKONEONLV <br /> V: ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONE ONLY <br /> m <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <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 DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(17) <br /> X� F-1CONTAINMENT BARRIER ICE) ❑ EXCAVATE TREAT(ET) ❑ PUM P&TREAT GROUNDWATER(GT) ❑ REPLACESWPLV(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED MN Q OTHER(OT) <br /> � y urc C o et, rte. <br /> A-I-I.L�t�17L <br /> HsC�l�%71 <br />