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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ �j ND REPORTBEEN FLED 7 I:HEREBY CERTIFY THAT I:AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> YES <br /> REI ❑YES ❑ No `'REPORTED THIS INFORMATION.TO LOC OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> THE HEALTH g Y <br /> H AND SAFTY CODE f% <br /> REPORT DATE CASES p/y 9 �C <br /> 0.1 u / IJ/�J "v / r .SIGNED •(.•.( DATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNTURE <br /> A Ao R Ski J4✓e 120 '/(o Tl 3 `i <br /> oREPRESENTING E::] OWNEWOPERATOR F-1REGI LBOARD COMPANY OR AGENCY NAME <br /> O LOCAL AGENCY ❑ OTHER <br /> ADDRESS DaqT �,! ./ U� �s^T- / ZIP <br /> NAME /�/+// / ////� �j CONTACT PERSON PHONE �,/ <br /> d/4G/�/ sZ J /A❑ UN �5 / 571 /s3 <br /> ADDRESS 433 ./ mown ` ' �f �S .��/. <br /> a „([,Yl, (/tel/) (/�(�{�•)' /"`/'1'N �� / Dm, ✓ / AAA'J" <br /> 8lATE zip <br /> FACLITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Pc�fyj�l -74 <br /> Q3z SSG <br /> S ADDRESS �O `w �j/ASM �r / ��� <br /> CROSS STREET 84/il€/Er T,PEOFAREA O COMMERCIAL Q INDUSTRIAL❑RURAL PE OF BUSINESS ❑ RETAIL FUEL STATION <br /> �.� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> g LOCALAGENCY �A/GEENCbbtA" CONTACT PERSON PHONE <br /> ~ RIG TH VVYrY PHONE ��j <br /> ( SI REGKNJAL 911 <br /> BOARD / 361�s6 W <br /> NAME . C QUANTITY LOS✓✓T(GALLONS) <br /> YH O O AL <br /> UNKNOWN <br /> (2) <br /> Q ❑ UNKNOWN <br /> I- <br /> DATE DISCOVERERI HOWDISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACE M041TOR14G ❑ NUISANCE CONDITIONS <br /> NAA M b �o v E] TANK TEST Q TANK REMOVAL OTHER -r[�j /C V�g4,J K 11449 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> >> UNKNOWN E] REMOVECONTENTS E] REPLACE TANK ❑ CLOSE TANK <br /> y¢ M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED 9 ❑ REPAIRTANK ❑ REPAIRPPING a CHANGE PROCEDURE <br /> p ❑ VES ❑ NO IFYES.DATE M M o D r v ❑ OTHER <br /> Q SOURCE OF DISCHARGE TANKS ONLYCAPACITY ATERIAL CAUSES) <br /> 4 ❑ TANKLEAK X UNKNOWN / i'7 o�`FiAL E] FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> J uS <br /> c6j ❑ PIPING LEAK AGE YRS �STEEL O CORROSION ❑ UNKNOWN <br /> ❑ <br /> OTt!JiR UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> �y CHECKO ONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> 2 N <br /> wm SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> a <br /> \ U% ❑ NOACTIONTAKEN ❑ POST CLEANUP 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) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> O TREATMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) �OTHER(OT) <br /> /WM //'t7lt/+c� St71✓L2 <br /> Offe dloNd eaV�x el✓ �.a Zs 11ven-'4�ae- 5'��di`+� a SSUSS <br /> dHG [tee I�4TK�i <br /> o/- a IN Ats vel u /z y e, R9LD IMt <br />