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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES vwOREPORT BEEN FILED T <br /> ❑ VES O YES ❑ O I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO.LOCAL OFFICIALS PURSUANT TO SECTION 25160.7 OF <br /> REPORTDATE CASE• THEHEALTHANq Sp}�'y COpE <br /> SIGNED E - <br /> NAMEOFINDIVIDUALFILIGREPORT PHONE SIGNATURE <br /> `a, e S c- 00) 416P-3yy1 <br /> REPRESENTING ❑ OWNER;OPERATOR ❑ REGK)NALBOARO COMPANY OR AGENCY NAME <br /> gLOCALAGENCY ❑ OTHER <br /> ADDRESSO I /` 0 0 <br /> uN STATE IIP <br /> mNAME `�'D� A `�T'� /��//.����� CONyT/A�CT PERSON I , q �/� PHONE <br /> � De,lia_ ' dle Jvw4if UNKGWN McZr Var ell-:%— ( )766r •/�l <br /> <y ADDRESS <br /> C� e v /� "fZoa o� sfari�vr- c H <br /> �� STREET CRY SLATE ZIP <br /> FACILITY NAME(F APPLICABLE) OPERATOR PHONE <br /> De! fia FI at i- S 4J l��l�� 7�ruti/�S�/eS ca 'flv4-5'141 <br /> ADDRESS 199 <br /> erD r rr�- Rd.. JIG�� <br /> 35-35- sTRE Dm KbI1MV I <br /> y CR SSTREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ <br /> /�� RETAIL FUEL STATION <br /> eU) ❑RESIDENTIAL ❑OTHER ❑ FARM Q OTHER <br /> LOC'AALYAGENCV AGENCY NAME NTACTPERSON PHONE <br /> w f� <br /> 5 ,. ( ) <br /> REGIONAL BOARD PHONE <br /> G > <br /> qq (1) (� NAME OUANTDY LOST(GALLONS) <br /> S , ,! wV dNKNCWN <br /> ❑ UNKNOWN <br /> i <br /> w DATE DISCOVERED HOW DI RED ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORWG Q NUISANCECONMgNS <br /> (J(j <br /> w !J M J 2 <br /> Y o D r TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Iw M M D D Y v UNKNOWN ❑ REMOVECONTEN7S ❑ REPLACETANK ❑ CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED Y ❑ REPAIRTANK ❑ REPAIRPWNG ❑ CHANGEPROCEDURE <br /> o ❑ YES ❑ O FYES,DATE .1 ml DI DI YJ Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLYiCAPACITY MATERIAL CAUSES) <br /> ❑ TANKLEAK D2,01LINKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION [� UNKNOWN <br /> ❑ OTHER ED UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> yw CHECK ONE NLV <br /> $� UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> gg CHECKO ,,INLV <br /> SIGNED <br /> F PLEANUP <br /> MPLETED OR <br /> ZS ,L❑jCf NOACTIONTAKEN INVESTIGATION I❑PROGRESS OST CLEANUP MONITORINGIN PROGRESS ❑ O FUNDS AVAILABLE PROCEED F❑ EVALUATGCLEANUPALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 91 ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) Q ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREATGROUNDWATER M ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> H ODa �P1u cv�, ct�sore <br /> lr`ne f f C--is lu-L, 7-e s, 7' <br /> OvL- P 1 3/—8�. � 4 `� <br /> 5 <br /> w s, <br /> a s .S ine,� vv.rr l� � r e <br /> i` <br /> b�tXBDLLSIAd1) <br /> - 1"�. � , <br />