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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FORLOCALAGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED 7 ❑YES ❑ NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE.AND THAT I HAVE <br /> REPORTDATEREPORTED THIS INFORMATION TO LOCAL OFFI IALS PURSUANT TO SECTION 25180.7 OF <br /> CASE# THE HEALTH AND SAFT/Y CODE <br /> 2 o{// <br /> M /M 3 1 p Y Y SIGNED C{.LZ-•. YKtA'LL 3 <br /> NAME OF INDIVIDUAL FILING REPORT <br /> PHONEDAT <br /> RSIGNATURE <br /> w REPRESENTING ❑ OWNEWOPERATOR LI REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 WLOCALAGENCY ❑ OTHER _ � <br /> ADDRESS I-1U/V /k/e- RY V-IZV64l VAI <br /> 21 NAME p Ly <br /> STATE <br /> ■ �Gk. CONTACT PERSON 1 e /� /PHOONE 2P <br /> onl O UNKNOWN I,E A-M e,{�� 1 F" 9�2-ya7 <br /> i ADDRESS U6 <br /> OO//I [/ <br /> ¢ V STREET U ..57 /n - <br /> FACRITV NAME(IF APPLICABLE) CRY SPATE NE 1 <br /> OPERATOR <br /> / PHONE <br /> ADDRESS <br /> �/]�/y/1 GL aLJ I <br /> �y ✓✓ D© S STREET ` DIT S/Vt/{ !U� <br /> y CROSS STREET 7 204 <br /> TYPE OF AREA 000MMERCIAL 2SWDU TRIALTYPE OF BUSINESS SINESS <br /> ❑ O RETAIL FUEL STATION <br /> LOCAL AGENCY <br /> RESIDENTIAL ❑OTHER <br /> ❑ FARM OTHER <br /> AGENCY NAME <br /> y - CONTACT PERSON PHONE <br /> w�y <br /> n REGIONAL BOARD �� PHONE <br /> C <br /> (() <br /> u NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> � DATE DlscovE D <br /> DNKNOWN <br /> iHOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M 'M 0, 'y. ❑ TANK TEST k TAN(REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN Tom( METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D p v y j41 UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> WAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPPN6 <br /> �[G ❑ CHANGE PROCEDUREo YES F-1NOIFYES,DATE M � p Y Y y ❑ OTHER <br /> ,yl SOURCE OF DISCHARGE TANKSONLIICM ITT MATERIAL CAUSE(5) <br /> 3 ❑ TANKLEAK [>5 UNKNOWN 7 {'.rJO/7 GAL ❑ FIBERGLASS ❑ <br /> ❑ OVERFILL RUPTURHFAILURE <br /> PIPING LEAK <br /> AGE YRS �STEEL ❑ CORROSION >jr UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ywy CHECK ONE ONLY <br /> (3� xUNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ¢< SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ 5KINEDOFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uy ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> w� ❑ CAPSITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(17) <br /> ❑ CONTAINMENT 13ARRIER( ) ❑ EXCAVATEATREAT(ET) PUMP&TREAT GROUNDWATER <br /> �I CB ❑ (GT) E:] REPLACE SUPPLY(RS) <br /> ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) OTHER(OT) S« 6/0MA4E4VTS <br /> y FVR-AM F D 45WI r4 r resp,./it, thtvf- Mille Tea. <br /> w SampLjWy "MA 5HP, 4SSe5Sm4v"4- N1GL Mteta4a <br /> 0( ek rvK i_n e, Ve24-a a, I AA-d G o R-I?,o 1,3-rft e,Kkv, - e F Co Kj-/At <br /> wAm 710i <br /> RSC06IN11 <br />