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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERV S FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 1 HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES NO ❑YES EvNO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF _ <br /> RT TE CASE# TH HEATH ANOSAFTY CODE. , / ` �— PQII <br /> tJ <br /> q//E�/pO ccr✓v Qa /0iQI L)oe rL i <br /> bu �M O 3.1l?r /v NED DATE <br /> N4&"F INDIVIDUAL F'ILyI GREPORT PHONE SIGNA <br /> � qm V/pLE r� (2D� yb8-3y6 G <br /> i REPRES NG F-1OWNEIVOPERATOR ❑ REGK)NALBOARD OOMPANYORK.ENCY NAME u <br /> LOCALAGENCY ❑ OTHERy i CT/ <br /> ADDRESSN S�/ .ToAQwAt s.. S r/ m,�/ cA 96Z06 <br /> D 1 STiiEET QTY WATE <br /> NAME /GIT CONTACTPERSON PHONE /yam <br /> ¢ 1-6,0/ Un//F�r�a 5('iFlcb�- v�5❑ UNKNOWN 811.,1— Su-TTod (2�)33l <br /> Q6 AM /S SS �Il, Zoa6hoRD ST, ZhDI CACITYE 9'52vo <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> L.U.s.� . -2W:5tbkTM/0N /'Er BILL 6vITOA/ 33/-3/�D <br /> Zp �S.J, 952yo <br /> sTREEr Cm CDUKTYap <br /> CROSSS((TT�REET �/ TYPEOFAREA O COMMERCIAL O INDUSTRLAL Q RURAL TYPE OF BU N S ❑�RR.E.�yTwA.,,IL,FUEL STATION <br /> =NU U 51w/04L &4 y ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER�,IA.A�L Y�I'Y1I <br /> LOCAL <br /> P: <br /> �Y AGENCY NAME OONTACTPERSON PHONE <br /> y 5 <br /> w59 <br /> w REG101JALARD PHONE <br /> C <br /> (7) NAME QUANTITY LOST(GAL ) <br /> 5j 46—nE' ,oq5OZJN5— _ UNKNOWN <br /> u� (2) <br /> r�i /y� ❑ UNKNOWN <br /> t NDIWVERED / o gy �v HOWDI RED F-1INVENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NIISANCECONDRIONS <br /> TANK TEST Q TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> w MI Mi DI DI YJ Yl of UNKNOWN ❑ REMOVEOONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? 11AXVDGJ ❑ REPAIRTANK ❑ REPAIRPPWG ❑ CHANGEPROCEDURE <br /> p ❑ YES ❑ N7 FYES.DATE M MI D D y y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYOCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOW) 11%000 GAL. FIBERGLASS ❑ OVERFILL O RUPTUREFA&URE <br /> F--] PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL O OTHER <br /> w CHECK NEONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECKONEONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> VNOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> OHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O CAPSITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(11) <br /> ¢t� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> In���.r �liK7z/�2 Sl1� �s�m��/7' LW�L f3� RSQUI R� ?D tri <br /> 7rj�/t/9'fl/� yN0 EXTE7V7 pF CpNT7471Y/A!/i77oY1/ iVi ��v/fir✓ 8 ✓ T7tE <br /> K#D06(IR!) <br /> RI-was <br />