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9O-u,8ty <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES [J- <br /> IJ�/NO REPORT BEEN FLED? KVES ❑ NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORTCATE CASE* IML <br /> �HLALTH AND SAFTY CODE <br /> DATE <br /> y NAME OF INDITV,IDUAL FLING REPORT PHONE ��r/I��v SIGNATURE <br /> REPRESENTING 11.•GG COMPANY OR AGENCY NAME <br /> w ❑ OWNEWOPERATOR ❑ REGIONALBOARD <br /> a LOCAL AGENCY ❑ OTHER (46 U SP ceps <br /> w <br /> ADDRESS 1L /laf� <br /> � S N <br /> I . SNa/✓ u,IJ3 FEf CRY �-/I WAI 26 71P <br /> w NAME CONTACTPERSON PHONE <br /> z SQ16o N ❑ UNKNOWN <br /> S a ADDRESS <br /> w ,M./. <br /> O S. 3fREET cr_ N CITY 64 SPATE .ZO ZIP <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> e -pG{ a <br /> ADDRESS . <br /> 820 <7 CRY N N COUNTY 520ro ZIP <br /> Pl CROSSSTREET <br /> Wo <br /> i LOCALAGENCV AGENCY NAMME+.,��, CONTACTPERSON PHONE �y� <br /> i W 4 6 �evILies Ckork' wf- ) d - #0 <br /> REGIONAL ARD PHONE <br /> a <br /> y 1 NAME QUANTITY LOST(GAUgwS) <br /> e4r,, ,J5 UNKNOWN <br /> ❑ UNKNOWN <br /> i <br /> DATEDISCOVERED HOW DISCOVERED ❑ JNVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> LAY1 q.1 OD -5 11 7YI0 v ❑ TANK TEST [jZ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN / METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Mi Mi ol 01 Yl Yl UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ZCLOSETMIX <br /> HAS OL4CFIMGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPWNG E] CHANGE PROCEDURE <br /> O YES ❑ NO FYES.DATE ml mi Di YJ Y ❑ OTHER <br /> w SOURCE OF DISCHARGECAUSES) <br /> F-1TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREFAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION dUNKNOWN ❑ OTHER <br /> w wp CHECK ONE ONLY <br /> f�F ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKWGWATER- (CHECK ONLY F WATER WELLS HAVEACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> b° <br /> F-1NOACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTIONCHARACTERPATION d <br /> �% ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING W PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY j <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE B DISPOSE(ED) ❑ REMOVE FREEPRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> 2 Ic£eua rwrx-rA� <br /> ❑ CAP SITE(CD) ❑ EX CAVATE 8 TREAT(ET) ❑ TNMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT 13ARFIIER(CB) ❑ NOACTIONREQUIRED(NA) ❑ TBEATMENTAT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(On <br /> M(A ffS .['el/�(1 s611 COr*f"fnJO14/ON, P64t'ne" Tf <br /> i fA <br /> 4s5Ps <br /> wUIT'e� -fe d�w)1NC -fAle �reZ?A-el C-i A* 070 <br /> ry jr,ftjf� h_ litaO �no�c / Ppu/a i a9NvcrPs <br /> ""7 7 ✓ ��hvesl <br />