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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES - <br />FOR LOCAL AGENCY USE ONLY. <br />❑ YES NO REPORT BEEN FILED? ❑ YES NX) <br />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 />THEME LIN AND DAFTY <br />REPORTDATE <br />Ll 7M ' <br />CASEA <br />SGNED DAit <br />✓ Y V Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />Wil-L-I-AKI, R�. <br />o0q) Y69-3 <br />' <br />L.c;___ <br />R <br />REPRESENTING ❑ OWNERIOPERATOR ❑ RE13IONALBOARD <br />COMPANY OR AGENCY NAME <br />LOCALAGENCY ❑ OTHER <br />ADDRESS 1{�1 <br />V G// �l�/O GWamV&aA/WATE(!�+ <br />c <br />NAMECONTACTPERSONI <br />F bl N (r ❑ UNKNOWN <br />aTr <br />/ PHONE <br />V I TejZ <br />6 <br />ADDRESS <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />� Lt .p' fj <br />�� <br />ADDRESS mm <c�) ,_ y� [' -I / 7 ,, <br />V � ` u' x ok S7 S7&; -rd )-( `_' 9 S -IN <br />�BTREET cm <br />SST <br />STILET <br />TYPE OF AREA [:]COMMERCIAL E] INDUSTRIAL ❑ RURAL <br />TYPEOFBUSINESS ❑ RETAIL FUEL STATION <br />❑ RESIDENTIAL [::]OTHER_ <br />❑ FARM ❑ OTHER <br />LOCALAGENCY AGENCY NAME D �s/ <br />CONTACTPERSON <br />PHONE <br />w <br />�N A L H� <br />c 6f�3�1 <br />a <br />REGIONAL BOA VR � �q <br />G <br />PHONE <br />36/�6v <br />� " NAME QUANTITY LOST (GALLONS) <br />N L,4R v -*5-d Grn% ❑ UNKNOWN <br />(2) <br />❑ UNKNOWN <br />DATEDISCOVEREED ��(/ <br />HOW DISCOVERED E] INVENTORY CONTROL E] SUBSURFACE MONITORING NUISANCE CONDITIONS <br />❑ <br />M M Z �+p f/v [/ v <br />TANK TEST F-1TANKREMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />Ml M Di DI Y I Yl UNKNOWN <br />❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />HAS DISCHARGE BEEN STOPPED 9 <br />❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br />c <br />❑ YES ❑ NO IFYES,DATE <br />❑ OTHER <br />M M D D Y Y <br />u� <br />SOURCE OF DISCHARGES <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK A UNKNOWN <br />1001) GAL ❑ FIBERGLASS <br />❑ GVERFLL ❑ RUPTURE/FALURE <br />❑ PIPINGLEAK <br />AGE 19 YRS STEEL <br />❑ CORROSION UNKNOWN <br />❑ OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />CHECKONEONLY <br />�3y <br />UNDETERMINED E:]SOILONLY 7] GROUNDWATER [:j DRINKING DRINKING WATER(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />z <br />ECK ONE ONLY <br />�� <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OFPROBLEM) ❑ CLEANUP INPROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />3 <br />F­1CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED 80 DEGRADATION (IT) <br />❑ CONTAINMENT BARRIER (CO) ❑ EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY IRS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REOUIRED(NA) OTHER (OT) <br />/ ectr✓ su a / 'G ,fie s/os✓ m <br />Yn-9k rJ2e.�f --f1) Gil eer„ine a `r�-�,r a �-ed e.�'{fiv�f o I� <br />�C <br />Ce�v7YA/�//�V/1'T/Df✓ /iS /Reol i1Y Q�j4R0/oR/R�G <br />s <br />,L/ / <br />N&G o5I71 <br />