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'` `,c <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES REPORT BEEN FLED 7 ❑YES E] NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> l� ''" ,REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.1 OF <br /> THEHEA TH DS 600E <br /> flEPORTDATEo J CASES k /� ��,. <br /> / M O M Y Y SIGS J OATE <br /> m <br /> NAME FINDIVIDUAL FPHONE <br /> ILING REPo$T�� n �0� ��� ���j SIGNA Ie" <br /> O REPRESENT G ✓l/❑RET <br /> REGIONALBOARD COMPANY OR AGENCY NAME [ <br /> p ACAAGENCY ❑ OTHER ❑ _San 'a jD <br /> ADDPE33 I ,Q -J�r a o0 9" S�oc_A4 v <br /> NAME '( CONTA TPERSON C� PHONE <br /> be,l�-a 7"ruc K SGC (mss ❑ UN DJOWN <br /> ADDRESS <br /> STREET CITY STATE ZIP <br /> FACLITY NAME(IF APPLICABLE) OPERATOR /PHONE <br /> be <br /> ADDRESS <br /> rV ZIP <br /> �u 53 5 • S,REET C IM <br /> y CROSSSTREET ^ ^ TYPE OF AREA O COMMERCNL INDUSTRIALORURAL TYPEOFBUSINES RETAIL FUEL STATION <br /> ,/K`JT//S(`Q O RESIDENTIAL O OTHER O FARM �O,TIER G <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Aiv-ba co PS - �, N. ` 16-f a Doll`t(,,d`-3ya <br /> M!II REGGIONNAL /n( PHONE <br /> BO �/ <br /> Y IF t V 4J <br /> (1) W Q S fV o ! I NAME QUANTITY LOST(GALLONS) <br /> (a �/L,.�rO�NC/NOWN <br /> ❑ UNKNOWN <br /> WVE IN <br /> DATE DISCOVERED J((} HDW DISCOVERED O INORYCONTROL ❑ SUBSURFACEMONITORG ❑ NUISANCE CONDITIONS <br /> I /M UM Do So " Y �Y ❑ TANK TEST AW(REMOVAL E:] OTHER <br /> DATE DISCHARGE BEGAN �/, METHOD USE STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o v v I2I UNKICS EMOVE CONTENTS ❑ REPLACETIWK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? 001 <br /> � C 9 ❑ REPAIRTANK ❑ REPAIRPPING E:] CHANGE PROCEDURE <br /> p ❑ VES ❑ NO FYES.DATE /M OM Uo 5f 1Y ❑ OTHER <br /> yy SOURCE ISCHARGE TANKS ONLYrAPACITY MATERIAL U}4 GNM(S) <br /> 3 TANK LEAK ❑ UNKNOWN GAL_ ❑ FIBERG S ❑ OVERFILL ❑ RUPTUREFAILURE <br /> ❑ PIPINGLEAK AGE YRS EL ❑ CORROSION 5�4�KNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECKON LY <br /> UNDETERMINED O SOILONLY O GROUNDWATER ❑ ORINKINGWATER. (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> f, CHECK ONE 11 <br /> Q6 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUPINPROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> w ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES rte) <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) V <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(n) (V�V <br /> ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER IGT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) O NO ACTON REWIRED INA) F-1 OTHER(OT) <br /> VOL,;' V� <br /> G{G s r s ✓✓°v�l.�uAt <br /> � <br /> uv <br />