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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />�/ REPORTBEENFLEDP <br />YES <br />FOR LOCAL AGENCY USE ONLY <br />I HEREBY CERTIFY THAT IAM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />TO 25180.7 OF <br />O YES NO <br />RE EEEEEETTpppED THIS INFORMATION TjO LOCAL OFFICIALS PURSUANT SECTION <br />TH1D�SAFTY OODE f j ` <br />THANREPORT <br />GATE CASE* <br />(21 M 6 o1 13Y17 v <br />ED DATE. <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONESIGNA <br />(Donna e ran <br />6 -34/-3 <br />o <br />REPRESENTING OWNEWOPERATOR O REGIONALBOARD <br />COMPANY OR AGENCY NAME <br />LocA <br />S <br />LOCAL AGENCY OTHER <br />S.T. <br />ADDRESS � CA <br />1 <br />,-I}`� n . c • I WATE 2P <br />6O/ E, R <br />NAMEm <br />CONTACTPERSON PH�O�NEQ <br />�1/- <br />Che -o/�eL 5Pi vi ce Cen*,r Q UNKNOWN <br />Lloyd G u m S 333-I <br />�3 03 5°C h ero KeL L -o cC i CA <br />sBEEr c MATE nv <br />FACILITY NAME IF APPLICABLE) <br />C h e ro%ee- Serv "c e n <br />OPERATOR PHONE <br />L� G ums l20 33-493 <br />tj <br />ADDRESS <br />5 �- d i S• <br />!_0• G hQ,� p <br />3 <br />y <br />GROSSSTREET <br />TYPE OF AREACOMMERCIAL 0 INDUSTRIALE] RURAL <br />TYPE OF BUSINESS O RETAIL FUEL STATION <br />O RESIDENTIAL Q OTHER <br />O FARM OTHER <br />ag <br />LOCALAGENCY NAME_ /� n <br />+lV V2 UI /i LocaJL �K Cc%7[�I 111 <br />CONTACT PERSON /� <br />I1G 16 �'d <br />PHONE <br />j� �D <br />PHONE <br />REQ)?NAL A <br />1%'IQ kc ro n <br />�n \/ors <br />cgl6� /�1--567 <br />It) NAME DUANTTIY LOST (GALLONS) <br />er 2 e 11 uNKNowN <br />O UNKNOWN <br />i <br />DATE DISCOVERED <br />HOWDISCOVERED O INVENTORY CONTROL SUBSURFACE MONITORING OUISANCE NCONDITIONS <br />p G <br />a M O [ .1 Or O r <br />TANK TEST :�<TANK REMOVAL E] OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />O REMOVECONTENTS O REPLACE TANK tqZZCLO8E TANK <br />y� <br />O <br />M M O ol Y Y <br />G O CHANGE PROCEDURE <br />REPAIRPPWAN <br />HAS DISCHARGE BEEN STOPPED? <br />—D <br />O NO IF YES. DATE �jREPAIRTANK <br />E] OTHER <br />,/VES M .1 Ov <br />v <br />NAI <br />SOURCE OF DISCHARGE <br />TANKS MATERIAL <br />CAUSES) <br />3` <br />Q TANK LEAK UNKNOWN <br />SOONLY,CAPACITY <br />/J .S�� GAL. Q FIBERGLASS <br />O OVERFILL O RUPTURE/FAILURE <br />O PIPINGLEAK <br />AGE YRS 52�,OEEL <br />O CORROSION _UNKNOWN <br />O OTHER <br />UNKNOWN O OTHER <br />O SPILL Q OTHER <br />w� <br />CHECKONEONLY <br />UNDETERMINED SOILONLV O GROUNDWATER O DRINKWGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />aaa���KF <br />CHECKONEONLY <br />ITE INVESTIGATION (DEFINING EXTENT OF PROBLEM) CUEAiNUP PROGRESSE::]SIGNED F F (CLEANUP MPLETED OR <br />SNOACTK)NTAKENN IO <br />�+ <br />TO <br />O POOSTSCLEANUP MONITORING IN PROGRESSO[] FUNDS UIIDSA O PROCEED Q EVALUAATTIING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />o <br />O CAPSITE(CD) O EXCAVATE& OMPOSE(ED) O REMOVE FREE PRODUCT (Fp) O ENHANCED BIODEGRADATION (IT) <br />K� <br />CONTAINMENT BARRIER (CB) O EXCAVATE B TREAT (ET) O PUMP6TREAT GROUNDWATER (GT) O REPLACE SUPPLY (RS) <br />O TREATMENT AT HOOKUP (HU) O NO ACTION REOUIRED INN O OTHER (01) <br />