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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI94 FOR LOCAL AGENCY USE ONLY <br /> ❑ YES VNO REPORTBEENFLED? O VES 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 /> REPORT AT <br /> OM / CASEt /7EALTH ANO YCODE <br /> M O 61 Y �io/ qpGI-1, <br /> 1 <br /> DATE <br /> E OFINDIVIDUA FILING REPORT <br /> PHONE SIG R <br /> l�ioLlerT �9) y68�µ1o9 <br /> REPRESFJRING ❑ pWNEWOPERATOR ❑ REGIONAL BOA RD SMP OR AGENCY NAME J�, <br /> D- LOCAL AGENCY ❑ OTHER ! 1 / ej1 D <br /> a <br /> m APLfL4D ESS(//_� {/./V ) /T /9#/i/./w�-�/ /_�/•J'/�yn 61:52-016 <br /> WY WATE <br /> NAME / �/ . 1 ❑ ' PERSON PH/JD�NEQ, { � <br /> K s `-G J�/A o/V UNKNOWN cf.v�l Uw w� <br /> d 2 3� r�o�Ta�I wAy -W�y /y r7� <br /> srnEEr DRY 7 LJ� 7(p <br /> FACILITY NAME IF APPLICABLE) OPERATOR d <br /> 's 6xxow 00)935-3Za6 <br /> ADDRESS ICtf'iMR-D REEVES <br /> 23fn0 EA-57- 5T; ABY �5, T A 953 (0 <br /> sTREE cm <br /> CRpSSSTREET TYPEOFAREA ❑COMMERCIAL❑INDUSTRIAL RURAL TYPEOF13USINESS <br /> /_��A/E ❑ RETAIL FUELSTATION <br /> /�/// ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> SND c <br /> us�741 REGIONAL BOARD <br /> PHONE <br /> oeNAME OUANTRY LOST(GAL <br /> UNKNOWN <br /> (2) <br /> w! ❑ UNKNOWN <br /> DATEDISOOVERED HORED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E::] NUISANCE CONDITIONS <br /> 0. 1 M I D D Y v WDI TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN Fly/,, TYEJ <br /> ETHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D v v E "''OWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPEDT UNKIJOUJ ❑ REPAIR TANK ❑ REPAIRPPINO ❑ CHANGE PROCEDURE <br /> p ❑ VES ❑ NO F VES,DATE OTHEfl M D DY <br /> u� SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> ,S$� ❑ TANK LEAK NKNOWNgff� GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREiFALURE <br /> Q F-1PIPING LEAK AGE YRS �TEEL ❑ CORROSION Y?"UWNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w i. CHECK ONE ONLY <br /> (3: ❑ UNDETERMINED SOIL ONLY O GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> g CHECKONEONLV <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 8W ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT 13ARRIER(CS) F—] EXCAVATE&TREAT(ET) ❑ PUMP&TRFATGROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTON REQUIRED INA) ❑ OTHER(07) <br /> F,41LEQ ®,T. eo97*6N 5/TE7�'sSESSM��//V7 76 <br /> /NE ytlE Nf+77//eE /Wo &x?EN7 op CoA17mn1N/I77~ 45 <br /> HsC�(4,17) <br />