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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY - <br /> REPORT BEEN FILED 7 I.HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES ❑YES ❑ NO ;REPORTED THIS INFORMATION TO LO L OFFICIALS PURSUANT TO SECTION 25100.7 OF <br /> REPORTDATE CASE& THE HEALTH MQ iP�Y CODE <br /> p y y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT E - <br /> REPRESENTpG ❑ OWNE IOPERATOR ❑ REGIONAL BOARD P O ENCY NAME <br /> S lL—if, L/OCALAGENCY ❑ OTHER <br /> ADDRESS / <br /> /D• D STREET CRY BfATE ZIP <br /> NAME CONTACTPE ON PHONE <br /> .gyp A2% ❑ S ) 93 (26 <br /> UNKNOWN <br /> a <br /> ADDRESS ��/.'/'A-`� <br /> 2133 STREET / CRY /V v� ATE ZIZIP <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> i ADDRESS <br /> STREET ✓• //I�/ CRY CWx Y P <br /> yCROSS STREET TYPE OF AREA MERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATK)N <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM EQf�ER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w5� <br /> w� REGIONAL BOARD PHONE <br /> ( ) _ <br /> (yJ NAME 1Dk MITRY LOST(GALLONS) <br /> Nz W <br /> Q' pP <br /> (2) <br /> y UM(NOWN <br /> I DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> ;NUISA�CONDITIONS <br /> s o o r y ❑ TANK TEST ANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wQ u u o o v YKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK SE TANK <br /> M HAS DISCH BEENSTOPPED7 ❑II ��fEPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IFYES.DATE M u D p v Y LJd"'THER <br /> SOURCE OF DISCHARGE TANKS ONLYOCAPAC17Y MATERIAL CAU (S) <br /> F-1TANK LEAK UNKNOWN �GAL. ❑ FIBERGLASS ❑ OVERFLL ❑ RUPTURE/FAILURE <br /> F-1 PIPING LEAK AGE 7_.� 2 YRS �TEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER KNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w lu CHECKONEONLY <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> 2H <br /> as ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> P+ ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ALUATING CLEANUP ALTERNATIVES <br /> NO <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> �z <br /> CAP SITE ❑ EXCAVATE&DISPOSE(ED) ❑❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 8K)DEGRADATION(IT) <br /> oO <br /> w� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMPB TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> a <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) Ea"06ER(OnO.0-P O� <br /> `i setNe� �t� ,9ss�sw�T iv/// Ac ,�6/ )4) <br />