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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 /> REPORTSEENFLED? ,u�( I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES NO ❑YES NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORTDATE CASE# THEH TH AND SAFiY 0F� . <br /> OM Y y �. 1 � Ls <br /> V <br /> SIGNED DATE <br /> NAM OF INDIVIWAIREPORT TLJRE <br /> TG I & (ZYoi) ��Q-�•/�PHONESIGNA <br /> V F <br /> q REPG ❑ OWpERIOPERATOR ❑ REGIONALBOARD OOMPANYORAGENCY NAME <br /> p AGENCY [:] OTHER <br /> ADDRESS / <br /> /k0/ E yAianJ �V� �f7zYi/ Ci9 �5�b <br /> sTaeer cRry &LATE z�P <br /> NAME CONTACTPERSONjee <br /> PHONE <br /> i¢ EG ❑ UNKNOWN <br /> S<y ADDRESS <br /> 11530 14) . � '� M� ;f�cvsl� TY ZIP <br /> 95 9 <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> /4530 �J. a4mig, /`7r LC -ry�TKn� ��/Ui n 95L6jc <br /> y CROSSSTREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL URAL TYPE OF BUSINESS ❑ RgE�T/ALFUELS_TATKKJ <br /> ,-r— ❑RESIDENTIAL ❑OTHER ❑ FARM ©OTHER / (Q l n—AJ <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> s ( <br /> �BIREGIONAL BOARD PHONE <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> y �1 NOWN <br /> H ❑ UNKNOWN <br /> i DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> M M o Do y y ❑ TANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> M M o o y r UNIOJOWN ❑ REMOVECONTENTS E::] REPLACE TANK ❑ CLOSETANK <br /> Q HAS DISCHARGE BEEN TOPPED? ❑ REPAIRTANK ❑ REPAIRPPWO E] AN <br /> CHANGE PROCEDURE <br /> p ❑ YES W FYES,DATE M M D o YJ v ❑ OTHER <br /> u� SOURCE OF DISCHARGE JjKONLY,CAPACITY MATEflIA1 CAUSES) <br /> TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFLL ❑ RUPTUREYFAILURE <br /> PIPINGLEAK YRS 0 STEEL ❑ CORROSION �IJWNOWN <br /> ❑ OTHER 1NKNOWN Eg 06HER ❑ SPILL ❑ OTHER <br /> wlu CHECKONEONLY <br /> ❑ UNDETERMINED EOs-0I1-ONLY 62]--GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> N <br /> D:s ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> by ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLETO PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION($)(SEE BACK FOR DETAILS) <br /> 4 F ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(In <br /> 0 <br /> 2 ❑ CONTAINMENT BARRIER(CR) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENTATHOOKUP(HU) ❑ NO ACTION REOUIRED INA) ❑ OTHER(OT) <br /> � rgo.-iA� :-�-Ea.✓n�^7 �z`year <br /> Nllcm(aa1 <br />