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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FON LOCAL AGENCY USE ONLY <br /> O THAT I HAVE <br /> YES REPORT BEEN FLED? [:]YES O NO REPORTED THIS NFORMATIONI HEREBY CERTIFY THAT I AMATO LOCAL OFFICIALSNPURSUANT DESIGNATED GOVERMENT LTO SECYEE TION TO <br /> REPORTOATE 43Y CASE# THE HEALTH A910 SMrTY�4E /�_ ' . <br /> M vD V1 Y SIGNED TE' <br /> NAME OF INDIVIDUAL FLING REPORT PHONESIGNATURE <br /> wiucAp" X. N� (-01)116 7y1-o /� <br /> REPRESENTING O OWNERIOPERATOR O RE IONALBOARD COMPANYOR AGENCY NAME _ <br /> ii LOCALAGENCYOTHER PR Lid, 14A`/U/ S �7vk<4 <br /> ADDRESS Q O S(Q✓r'�" ( 5-z4/ <br /> STREET DRY ATATE ZIP <br /> NAME <br /> m CONC.PEON PHONE <br /> 5,+N y /1 W UNKNOWN ; I'm M w/ 4c3 <br /> 19 0 <br /> ADDRESS / S /0 C/- I '7J 6 <br /> WATE P <br /> FACILITY NAME(I-APPLICABLE) OPERATOR PHONE <br /> Q 5414 J-oAr CV a '(,U# " 's I f3 / <br /> 10 <br /> J ADDRESS <br /> W6ZIP <br /> Gv G� D�K Y gs3 z� <br /> w CROSSSTREETTYPE OF AREA O&MMERCIAL Q INDUSTRIAL Q Rlifilk TYPE OF BUSINESS O RETAIL FUEL STATION <br /> 4<Af.<h 0 RESIDENTIAL Q OTHER O FARME:] OTHER <br /> LOCALAGENCY AGENCY NQM,xi Je CONTACT PERSON PHONE <br /> z q l I 3 t '/6'�'3�f <br /> w <br /> w REGIONAL BOARD PHONE <br /> C J K W o )36/-S6aa <br /> % (0) NAME QUANTITY LOST(GALLONS) <br /> In ra (e i,� (n GA2h�N3 �CUNKNDWN <br /> �i O UNKNOWN <br /> DATEDISCOVERED O HOWDISCOVERED O INVENTORY CONTROL O SUBSURFACEMONITORNG O NUISANCEIXONDITIONS <br /> LI M 5 D � v� Y I] TANK TEST X TANK REMOVAL E] OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D x v UNKNOWNO REMOVECONTENTS O REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE SEEN STOPPED? O REPAIRTANK REPAIR PIPING CHANGE PROCEDURE <br /> p F-] YES O NO IFYES,DATE M M .1 DI YJ Y O OTHER <br /> w SOURCE OF DISCHARGE 11TTANKS ONLYr-VACITY MATERIAL CAUSE(S) <br /> O TANKLEAK 'UNKNOWN IOA66-i '0106d GAL O FIBERGLASS O OVERFILL RUPTUREIFAILURE <br /> t� PIPINGLEAK AGE 11-7-7YRS STEEL O CORROSION UNKNOYIN <br /> O OTHER O UNKNOWN OTHER O SPILL X OTHER <br /> w CHECK EONLY <br /> �Z UNDETERMINED O SOIL ONLY O GROUNDWATER O DRINKING WATER (CHECK ONLY FWATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> r CHE ON=ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U m O NO ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 <br /> O CAP SITE(CD) O E%CAVATE 8 DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> O CONTAINMENTBARRIER(CB) O EXCAVATEb TREAT(ET) O PUMPB TREAT GROUNDWATER(GT) O /REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NOACTIONREQUIRED(NA) OTHER(OT) <br /> Sc!'L vW141 F oAl lk <br /> Yeo deal at i:A }prN (c a, of pI p/ �j ✓al s o� /d-Z6- 8 � <br /> xi IcAe2 9" SSlsSy( [t��L(� a N¢quTieeo� Aef e2vr* s+�e <br /> AA'b4 rG N O� �i` CO!✓Ti9 Nt fii✓�TID Kl:2GoI Fl r <br /> L <br /> KxmtLell <br />