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9a it �o <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGFFJJNICYSERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES VNO REPORT BEEN FILED? r,[_ES ❑ NO 1 HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE.AND THAT I HAVE <br /> LLJJQQ y5( REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180,7 OF <br /> REPORTDATE /^/ CASE# THEHE HEAL A D�CODE G <br /> DM1 17i G M Y✓ Y SIGNED <br /> E <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT RE <br /> /Ps 141,t ) f7 -3 a <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY —] OTHER ^ 1 S <br /> ADDRESS gh <br /> Dn N COY STATE / P <br /> NAME -� CONTACTPERSON PHONE /p <br /> Ha A.A UIN 2,/��pr.LN ❑ UNKNOWN t—d J7l(/Ct �• ) p0— <br /> i ADDRESS <br /> N C <br /> c• STREET C" CA STATE ap <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> S4oc 4N 01 ►r f *G > 68--5(906 <br /> i <br /> ADDRESS; Vw S. Ortar u OC Cm N r OV <br /> ap <br /> CROSS STREET TYPE OF AREA O COMMERCIAL DUSTRIAL Q RURAL TYPE OF BUSINES RETAIL FUEL STATION <br /> C t,, IX oN ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER <br /> g LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> / In) lt?=3wo <br /> yl REGIONAL BOAFP PHONE <br /> H (I) NAME QUANTITY LOST(GALLONS) <br /> e{ro hw c, s ria-emNKNOWN <br /> �- ❑ UNKNOWN <br /> Z DATEDISCOVERED HOWDISOOVERED O VENTOfiY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCEODNDITION5 <br /> o D v Y ❑ TANK TEST VTAKK REMOVAL ❑ OTHER <br /> DATE DISCHAR EBEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> LLx M M o o v Y R/LNKNOWN E:] REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> �n HAS DI ARGE BEEN STOPPED? f� h ❑ REPAIRTIWK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> 2905 ES ❑ NO IFYES,DATE �j V o rl/Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY�CCAPACITY MATERIAL CAUSE(S) <br /> O TANK LEAK UNKNOWN0026 S GAL. ❑ FIBERGLASS ❑ OVERFILL �REFAILURE <br /> ❑ PIPING LEAK AGE YRS ,LV_f/STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> �� ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKON'EONLY <br /> w E] SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F—] CLEANUPIN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> UH ❑ NOACTIONTAKEN ❑ POSTCLEANUP MoNTORWGIN PROGRESS ❑ NO FUNDS AVALABLETO PROCEED ❑ EVALUATINGCLEANUPALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> b ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E] ENHANCED BK)DEGRADATION(IT) <br /> 2� ❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT ATHOOKUP(HUI ❑ NOACTONREOUIRED(NA) Q OTHER(OT) <br /> `ro (Y N+OVG 5 50-1 (r3u peve-[( Sprl COA.,{aM/N /D.V �N/'�jiM S/f' csSSPS/r/P� <br /> &"(/de teyur�� -/. d,?*rm/,je -#e ,vcrlu..e 4A,61 <br /> /n/6 -fM'M /a'P/aL5 'fo rO,hR*7n /d/� yc/Sf 00P 10r' /TP.P11'ILtiY/S O'� f�'.C. nsc`s l«en <br />