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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYT-��, HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES - REPORTBEENFLED7 / I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> LLLJJJ .-�VES ❑ NOREPORTEDTHIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORTDATE pl CASEI THE HEALTH AND SAFTYAODE <br /> 0 Ml If M Y1 f Y SIGNED � � � <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> G'u.-a/ oL (moi) V&k-aycva <br /> P.. REPRESENT G � OWNEFVOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER o C //-Q MX v/ � <br /> ADDRESS OS d0 q !�C <br /> ., s� c s <br /> NAME <br /> uJ CONTACT PERSON ,/ PHONE <br /> i <br /> ZQ e /PCf ZeD UNKNOWN !/a/�e//CL <br /> flTlPiii a ADDRESS <br /> 3=Gs CLwcv, 2c/ �S/vG/c{�., CA 4sPivS <br /> DAV &TATE ZIP <br /> FACILITY NAME(IF AF'JCABLE) OPERATOR B/'L[CP PHONE <br /> D / ! - .Della Tyr ,E / y (poy) UIoG- <br /> ADDRESS <br /> ,535 C herak.�e leo( c�/oc.Efa�, cSan �ct/r� `lsdv <br /> y CROSSSTREET TYPE OF AREA Q COMMERCIAL DfrINDUSTRIAL❑RURAL TYPE OF BUSINESS TAIL FUEL S`ATION <br /> NLW, �(� ❑RESIDENTIAL OTHER ❑ FARM THER <br /> g LOCALAGENCY uzz <br /> AGENCY NAME CONTACTPERSON PHONE <br /> ��• REGIONAL BOARD PHONE <br /> m lt) NAME OUANTTTYLOST(GALLONS) <br /> e /e q s /!' ❑�M�F+ <br /> (a <br /> ❑ UNKNOWN <br /> i DATEDIS�CjOVERED 1 HOWDISCOVERED ❑ INVEWORYCONTROL ❑ -SUBSURFACE MONITORWG ❑�NUISANCE CONDITIONS <br /> J2. O M � D off'o Y y ❑ TAWTEST ❑ TAW REMOVAL EK OTHER IIIeRk a1(y' <br /> DATE DISCHARGE BEGAN F[j}' 1/u METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w u u D D Y Y U `NKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANOEPROCEDURE <br /> O ❑ YES ❑ NO IF VES,DATE MI MI D D YJ Y ❑ OTHER <br /> in SOURCE OF DISCHARGE TANKS ONLV�CAPACRY MATERIAL CAUSES) <br /> ❑ TANK LEAK UNKNONTI 0 GAL. ❑ FIBERGLASS ❑ OVERFLL ❑ flUP AILURE <br /> c� ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY GROUNDWATER O DRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE Y <br /> INVESTIGATION IN <br /> RESS(DEFINING <br /> NT OF <br /> CLEANUP <br /> SIGNED <br /> PLETED OR UNNECESSARY) <br /> U ❑ NOACTKINTAKEN [::] POST CLEANUP MONITORING GIN POROGRESS❑❑ NO FUNDS�RLA13L TOPROCEEDO�❑ EVALUCATTIING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 8 F-1CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED SK)DEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ UMP&TREAT GROUNDWATE[RT)Q❑�REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HI ❑ G ACTION REQUIRED INA) �THER(07) <br /> 80D8 �a/ rey, vasoll- Mink le-ak de)kcfor <br /> Gron /r....<na/ran pf ex cava�cc/ Soi/. Fulf�r siTF �sstss.,Le,,� w�!/ <br /> hifire to /! 4-- e.C+pLYL &Jr �pn �,Yn<c7/COn <Gs <br /> Hl <br />