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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY/ HAS STATE OFFICE OF EMERGENCY SERVIC <br />REPORT BEEN FLED? <br />FOR LOCAL AGENCY USE ONLY <br />HEREBY CERTIFY <br />❑ YES�/„ <br />LJ w'o ❑ YES <br />_I THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />'REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />THE HEALTH AND SAFTY CODE 1 <br />REPORTDATE CASE# <br />32 <br />q'i <br />M N <br />slcnEo <br />NAMOFINDIVIDUAL 1=ILi REPORT <br />PHONE <br />SIGNATURE <br />m <br />y D <br />V691v&,i <br />�u <br />REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONAL BOARD <br />dLOCAL <br />COMPANY ORAGENCY NAME <br />4 <br />AGENCY ❑ OTHER <br />1 <br />D: <br />ADDRESS <br />NAME <br />CONTACT PEgSON <br />❑ 11NNOWN <br />/PHONE <br />`� - <br />ADDRESS <br />FACILITY NAME (F APPLICABLE) <br />O RATOR <br />/PHONE <br />ADDRESS- <br />�550 w. dzc.0 cS'�4 eek � �L�a`e�`- 9Szo3 <br />��T cm couNrr P <br />m <br />CROSS �E <br />i <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />P: <br />5 <br />( � 9w3 2c <br />o i <br />REGIONAL BOARD <br />PHONE <br />w <br />l7) NAME QUANTITY LOST (GALLONS) <br />F <br />[UWNDWN <br />z_ <br />(2) <br />❑ UNKNOWN <br />W <br />DATEDISCOVERED <br />J <br />HOWDISDOVERED ❑ INVENTORY CONTROL SUBSURFACE MONCZ ❑ NUISANCE CONDITIONS <br />u u o r <br />❑. TANK TEST E::]TANK REMOVAL BOTHER �)/L e/A1 <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />i <br />Ml Ml 01 DI Yl r ❑g -'O KNOWN <br />❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSETANK <br />HAS DISCHARGE STOPFED7 <br />❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br />O <br />F-1YES7ND FYES, DATE❑ <br />OTHER <br />M M D D Y V <br />O <br />SOURCE OF DISCHARGE <br />CAUSES) <br />j� <br />26 <br />❑ TANK LEAK �' UNIQJOWN <br />❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br />❑ PIPINGLEAK ❑ OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER <br />H Wa <br />CHECKONEONLY <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRIM(NGWATER-(CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />g <br />sK <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBM FTTED ❑ POLLUTION CHARACTERIZATION <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING N PROGRESS <br />❑ REMEDIATIONPLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />z <br />CHECK APPROPRIATEACTION(S) ❑ EXCAVATE B DISPOSE (ED) E] REMOVE FREE PRODUCT(FP) ❑ ENHANCED Bq DEGRADATION (IT) <br />Pff%rxro 7 <br />8 <br />❑ CAP SITE (CD) ❑ EXCAVATE L TREAT(ET) ❑ FRUMP 8 TREATGROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ CONTAINMENT 13ARRIER(CB) ❑ NO ACTION REQUIRED MA) ❑ TREATMENT AT HOOKUP(HUI ❑ VENTSOIL(VS) <br />❑ VACUUM EXTRACT (V.E). ❑ OTHER(OT) <br />y <br />C,Qj <br />'Z` <br />�_,/ <br />�.fUI<(1%rlJLi V�/,� 71.. �M/ /S G•�/ ,f1L,,L Lx- 4tv -tA-k... <br />Y/%y <br />V XSC0.5 (11/B9I <br />�,tUrr� <br />