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fl - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFKE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YESVE <br /> REPORT BEEN FLED? 1 HEREBY CERTIFY THAT I AM❑YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS IGNATED NMENT EMPLOYEE AND THAT I A <br /> U UANT TO SECTION 25180.7 OF <br /> REPORTOATE CASES THE HEAL AND ,Y WDE <br /> M o�M D I `f YI Y SG#fECVDATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> Xe+; ' cL Re-sck %e-34 13 <br /> n REPRES ING ❑ OWNERIOPERATOR ❑ REGKNJALBOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER <br /> `�1 <br /> ADDRESS � <br /> i Vr <br /> TE <br /> NAME /� , /,tel �� �p f7N� OONTACTPERSON <br /> m W TrU✓/ \ S/ic-�-rn�-' ❑ UNKNOWN Y A <br /> ADDRESS <br /> P In �e�x moo ' /�/� l C/9 �� <br /> S�DRr BfATE ap <br /> PHONE <br /> FACILITY NAME IF APPLICABLE) (, P OPERATOR <br /> 'G� G/ <br /> 1u <br /> ADD"�.� Cl�.�-sT` �- CJ, F5ab5 <br /> q CROSSSTREET TYPE OF AREA OCOMMERCIAL O NDUSTRWL❑RURAL TYPE OF BUSINESS O RETAIL FUELSTATION <br /> R ❑RESIDENTIAL O OTHER O FARM O OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> y( REGK)NAL BOA PHONE <br /> 3 <br /> pl _ NAME OUANTIIY LOST(G UNKNOWN <br /> g2> (Z) /�� �✓ <br /> - ❑ UNKNOWN <br /> b DATEDISCOVERED J((� HOWDISCOVERED E::] INVENTORY CONTROL ❑ S BSURFACEM TORNG NUISANCE OONDnlONS <br /> /M ' M DOD " Y I V ❑ TANKTEST ❑ TANK REMOVAL �THER <br /> DATE DISCHARGE BEGANMETHODU TO STOP DISCHARGE(CHECK ALL THAT Y) j <br /> M M D D v v UNINowI REMOVE CONTENTS ❑ REPLACE TANK eLOSE TANK <br /> HAS DISC EBEENSTOPPED4 Om, ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> p YES ❑ NO DYES,DATE /M OD -5 r ❑ OTHER <br /> SOURCEOF DISCHARGE TANKS ONLYAAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK - UNKNOWN rs l J GAL ❑ FI ROLA33 ❑ OVERFILL ❑ RIATUREFALURE <br /> ❑ PIPINGLEAK AGE YRS STEEL ElCORROSION UNKNOWN <br /> O OTHER UNKNOWN OTHER ❑ SPILL O OTHER <br /> w� <br /> Cl-IECKONE LY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED <br /> g CHECKON'-:ONLY <br /> 6 ❑ SI INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E::] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> VH NOACTON TAKEN ❑ POSTOLEANUP 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) ❑-I REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATKN(IT) <br /> O CONTAINMENT BARRIER(CB) ❑ E%CAVATE&TREAT(ET) n PyMP&TREAT GROUNDWATER(G7) ❑ REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REOUIRED INA) �L^/� OOTHER(OT) <br /> Lahv?ayS Ot�I� r- 4 <br /> /Ll <br /> �. 8 .f-meq <br /> �' �. <br />