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4 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERG SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES � REPORT BEEN FILED? YES ❑ NO I HEREBY CERTIFY.THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> LL�II REPORTED THIS INFORMATION T0.LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE$ THE HEAL ND SAFTY CODE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE NUNtU <br /> SIGNATURE <br /> REPRESE ING ❑ OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 LOCAL AGENCY ❑ OTHER <br /> n <br /> �N <br /> ADDRESS (C�r <br /> NAME $TATE ZIP <br /> CONTACTPERSON PHONE <br /> i¢ I, ❑ UNKNOWN <br /> der rn�w bb ) 3�6 6 9! <br /> y ADDRESS <br /> 'C A�, Scc`fo 93IS'SJ <br /> FACLITY NAME IF APPLICABLE) OPERATOR PHONE <br /> Te ( Y S O,n l ) Y46-ffSod <br /> ADDRESS II <br /> 10 3 N S-f-ree f- C4 5 <br /> COAMECROSSSTREET TYPEOFAREAORCIAL❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS <br /> O RETAIL FUELSTATKN^ <br /> E::]RESIDENTIAL O OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> �Sct�,i�o ,Zocr%� uea&t <br /> REGIONAL BOARD C PHONE R t c) GB <br /> c I <br /> (1) NAME OU NTRY LOST(GALLON <br /> UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> i <br /> DATEDISCOVERED !Y1 IIDW DISCOVERED ❑ INVENTORY CONTROL E::] SUBSURFACE MONITORING ❑ NUMMIDECONCITIOW <br /> vM oA /D D CJ v r ❑ TANK TEST E] TANK REMOVAL E::] OTHER <br /> If <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> TKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> M M D D Y V <br /> Q HASDISC GEBEENSTOPPEDT q Lf TT���REPAIRTANK REPAIRPWING ❑ CHANGEPROCEDURE <br /> 'p YES ❑ NO IFYES,DATE ©M J 'M 1 0 .1 ?v r L=.1 OTHER .er <br /> u� SOURCE OF DISCHARGE TANKS ONLYA;APACITY MATERIAL CAUSES) <br /> q F-1 NK TALEAK DISCHARGE <br /> GAL, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> a ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ©UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ww CHECK ONE ONLY <br /> n <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Fg CHECK ONLY <br /> $$6 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ON ❑ NOACTKONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUPALTERNAl1VE3 <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(00) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> �ta ❑ CONTAINMENT BARRIER(CB) O EXCAVATE TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) E:] REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(W ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> Fai lore ® f %y1L levrvsl*e" *PSI`' �Yi :e Se <br /> ra <br /> r71vt, SI Y e{ eSS' <br /> CvL.2 �n a �.` <br /> Q sj,", <br /> j <br /> wca&HM !J <br />