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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED 7 <br /> F-1 YES NO ❑VES ❑ NO IHEREBV CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORT .REPORTED THIS INFORMATION TO L�AL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> TE/ CASE# THE HEALTHN SAFTY <br /> _ <br /> r <br /> NAME OF INDIVIDUAL FLING REPO pT SIGNED DA <br /> PHONE SIGNATURE <br /> O REPRES UNG <br /> ❑ OWNER/OPERATOR ❑ REGI BOARD COMPANY OR AGENCY NAME <br /> 8 LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> yvS/V, f.9i✓ �joA6Z�.t �r� 5% S�vc,�i� <br /> NAME A clry WA <br /> CA <br /> !LI�j Z/ dN CONTACT PE�/sO,N- D' PHONE <br /> a UNKNOWN <br /> ADDRESS ��J7 P ❑ ✓W K5 ( w 9 �J /�/l/b/ <br /> / 1 o Ero L4 W efATE <br /> FACLITY NAME APPLCABLE) OPERATOR ZIP <br /> /�./J ��r) <br /> D l- / .E �(V /z(c4v4, `�O PHDNE 0�3� L�� <br /> ` ADDRESS , a <br /> RM 2 6 0 'S7 < <br /> Y If <br /> - CROSS STR ET TYPE OF AREA <br /> L[—]INDUSTRIAL RURAL ESS E::] RETAIL FUEL STATION <br /> ❑ FARB�✓�G ❑RE3E OTHER M <br /> ❑ OTHER <br /> g LOCAL AGENCY — AGENCY NAME CONTACTPERSON PHONE <br /> REGIONAqBOARD <br /> PHONE <br /> x Ii) NAME <br /> w Ol LOST(O <br /> p, O nlS ❑ UNKNOWN <br /> (2) <br /> ❑ UNKNOWN <br /> b <br /> DATEDISCOVERED HOW DISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACEMONRORNG ❑ NUBANCE CONDITIONS <br /> AMM D D y y ❑ TANKTEST7TANK ❑ OTHER <br /> DATE DISCHARGE BEGAN SE STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> M M D D Y Y ❑ UNKNOWMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 PAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> 53 ❑ YES ❑ NO FYES.DATE M M D 0HER <br /> u� SOURCE OF DISCHARGE TTAANNKKSSJ LLYY� A ITy`�) MATERIAL CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN .7 ✓"- 7JJ pA[ FIB GLASS <br /> JJ O ❑ OVERFILL ❑ RUPTUREFALUIiE <br /> c ❑ <br /> PIPINGLEAK AGE YRS TEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> wCHECKONEONLV <br /> UL <br /> � ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON=ONLY <br /> �m <br /> < SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROS EAI) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> K3" ❑ NO ACTION TAKEN ❑ POST CLEANUP MONTTORNG IN PROGRESS ❑ NO FUNDS AVALABLETO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(GD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(m <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(FIB) ` <br /> ❑ TREATMENT AT HOOKUP(I" ❑ NO ACTION REQUIRED INA) ❑ OTHER(07) <br /> Soil oc, G✓ay`eoc r'"u htr e v /a/s377 m-. <br /> 16-STS rC4—p .ov-a ' &N h t�e 2 c ✓A#�iv �J.�-s <br /> b H� eat°a eIe <br /> /.r b y o /3jJjnro�vlYs� ••n <br /> rdf,14 /.tom le/ 4-14ol,may, <br />