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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY U EONLY <br /> ❑ YES F-1 <br /> REPORT BEEN FILED ❑YES ❑ NO REPORTED 1 HEREBY CERTIFYINF AA T ESLOCAAL OFGCIALSNMENT EMPLOYEE AND THAT I PURSUANT TO.SECTION 251801AOF <br /> REPORTDATE CASE. THE HEAL N S E <br /> � UIs- <br /> /� C � <br /> vM S'M � `I o �v I r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Ci, &A�ks (2-0d 46&-34V,.2 <br /> REPRESENTING ❑ OWNERIOPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> GT LOCALAGENCY ❑ OTHER <br /> S ✓ c <br /> ¢ ADDRESS C� <br /> (bol <br /> $LATE zp <br /> NAME CONTACT PERSON PHONE <br /> evt Va\2 V.2 ❑ UNKNOWN S�'ev� VcAeKT ,4- 3 -4926 <br /> n ADDRESS <br /> z31 s � o� C-A- �sZo <br /> S ATE p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> S (�¢ es ✓ v CP— S�evt v a�e G <br /> ou011463 -`I`.i� <br /> ADDREss <br /> To L, szo q <br /> IIuu Z-�I$ IV ta-� �✓y aet� cm ~ c <br /> m CROSSSTTR/BEET TYPEOFAREA ❑COTAMERCLAL 0 INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> ESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME OONTACTPERSON PHONE <br /> m <br /> (Z09) 46fi-1UL8 <br /> REGIALBOARD <br /> «� PHONE <br /> a� Cie•.-E✓.1 V�,IIe <br /> (916)3�/�,s6o0 <br /> y (1) NAME ` I OUANTITY LOST(GALLONS) <br /> f alCv.+. Avg. Ca✓`z�..s UNKNOWN <br /> r2 <br /> UNKNOWN <br /> k DATE D� �IS1COVERED ` HOWDISCOVERED ❑ INVENTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISAINCEODNDITIONS <br /> 0 M y M OD o Y Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o .1 v 'I UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED T ❑ REPAIRTANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> S w YES ❑ NO IFYES,DATE OM 4 mi 2, 0 c v �v ❑ OTHER <br /> m SOURCE OF DISCHARGETANKS ONLYJCAPACITY MATERIAL CAUSE(S) <br /> I`y'� <br /> ❑ TANKLEAK / UNKNOWN GAL, E}❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURErFAILURE <br /> U ❑ PIPINGLEAK AGE YRS XI STEEL <br /> ¢ 7" ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER 0 SPILL ❑ OTHER <br /> wLy CHECKONEONLY <br /> uit F--] UNDETERMINED SOIL ONLY E::] GROUNDWATER E] DRINKING WATER- (CHECK ONLY P WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> y <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEIA) 0 CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 80 ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE 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 BARRIER IDS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> 011 (q yj`'o�AMj1r� c,�io�. v�.a'4cd d.A✓;hyy -\a-a� ✓'�"�-Avc.l . � con +�ryrek <br /> wi-f+� Loll ra so <br /> N%��fare>t <br />