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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 /> ❑ <br /> YES REPORT BEEN FLEDT OYES NO I HE EBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPO TED THIS INF MATION TO LOCAL OFFICIALS PURSUANT TOCTION 25180.7 OF <br /> /REPORT DATE CASE• THEN ANDS CODE / <br /> LE — <br /> M I D Y Y SIGNED DAT <br /> ME OF INDIVIDUAL FILI REPORT PHONE SIGNq URff <br /> �u REPRESENTING O OWNEWOPERATOR O REGK)NALSOARD C9MPANYOR ENCYN <br /> 0 LOCALAGENCY OTHER / JJ <br /> w <br /> � ADDRESS <br /> SiaEFT DRY MTATE <br /> 3 <br /> Fw NAME CONTACTPERSON PHH/O..NNE�E (�[] <br /> S A ❑ UNK OWN <br /> ADDRESS <br /> I, <br /> @7 a Er T- w Dm STATE CgL 2!52L40 <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> knNisTRA tees Kew <br /> ADDRESS <br /> CROSS STREET <br /> P � <br /> Cg ALAGENCY AGENCY NAME TACXTPERSON PHONVIAUPI) -MsbE <br /> w <br /> d�Hf GIONAL BOARD PHONE <br /> c P� L <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> O UNKNOWN <br /> Fz DATE DISCOVERED HOWDISCOVEiED O INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> 0-1 G <br /> / .1 r O TANK TEST TANKREMOVAL O OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALLTHATAPPLY) <br /> ;Ry VECNTENTS REPLACE TANK CLOSE <br /> CLOSE TANK <br /> N u D D v Y <br /> Q HAS DISCHARGE BEEN STOPPED I11 //-- O REPAIRTANK O REPAIRPIPWO O CHANGE PROCEDURE <br /> S YES O NO FYES,DATE Q 4M lD 1(Jy ❑ OTHER <br /> G SOURCE OF DISCHARGE I CAUSE(S) <br /> 29 O TANK LEAK UNKNOWN O OVERFILL O RUPTURE/FAILURE O SPILL <br /> 0 PIPINGLEAK O OTHER O CORROSION UNKNOWN O OTHER <br /> w wp CHECK ONE ONLY <br /> K�F UNDETERMINED O SOIL ONLY O GROUNDWATER O DRINKNGWATER. (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢ NO ACTION TAKEN O PRELMA sum IT IO <br /> NARY SITE ASSESSMENT WORKPLAN SUED POLLUTION CHARACTERIZATION <br /> aH O LEAK BEING CONFIRMED O PRELIMINARY ASSESSMENT UNDERWAY O POST CLEANUP MONITORING N PROGRESS <br /> O REMEDIATION PLAN O GABE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) O REMOVE FREEPRODUCT(FP) O ENHANCEDBODEGRADATON(IT) <br /> 1�e•cwraio[r/Aal <br /> wig O CAPSITE(CD) O EXCAVATE&TREAT(ET) ❑ Tq)MP&TREATGROUNDWATERK31D O REPLACE SUPPLY(RS) K� <br /> ¢� ^l� <br /> O CONTAINMENT BARRIER(CS) O NO ACTON REQUIRED INA) O TREATMENTAT HOOKUP(HU) O VENTSOIL(VS) <br /> O VACUUM EXTRACT(VE) O OTHER(OT) e <br /> � Ntsn�, IS 3L`�►-�v- P��c-� -rte - Imo- L � <br /> CJD R,E�uz�T �� �.�Il�lrlll°cl�-8'N • Fll-C1�1'f� SLT� l►JVESTL�n-av-� (s O <br /> S -D L'�GR- I,W E 7i+E A 1lA R C{Wb 5cTEy T� 8 G C�N71MM L N RT'^ <br /> IIMDauuex <br />