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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI S FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I.HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT HAVE <br /> O YES NO YE9 'RE THIS INFORMATION T LPL OFFICIAL PURSUANT TO SECTION 25180,7 OF <br /> THE EAL A YCODEf� p <br /> REPORT g/ <br /> RT ATE CASES L �l <br /> Dw M 0 D Y I Y '..SIG D DATE <br /> NA INDIVIDUA��LF INGREPORT PHONE SIGNATU <br /> �/I1 Yro�€TT (o$ <br /> 768-3N6 <br /> REPRES NG O OWNERIOPERATOR Q REGIONALBOARD COMPANY Ofy@yG�'E/(aCYNAME�� ^ <br /> LOCAL AGENCY ❑ OTHER r'r'JJ/ 5 D <br /> "°° 85 Alo, S Jo�+Qvi�/ sT SmC���v 95Zob <br /> qTy STATE ZIP <br /> STFEET <br /> ACT PERSON <br /> � PHONE <br /> • �,sj ,bk7AL 7&V o WKNDWN l icK ��scNA NES 9 y66-oy9/ <br /> € 0t8 57DCkroA/ CA 95206 <br /> n ADO'p/�{S <br /> AAAW // O 0 �O Y STHEEf CRY VETE LP <br /> 5 FACIIILIITY NAME(IF <br /> CCCAPPLICABLE) r .ice /�C <br /> OPERATOR PHONE <br /> C /�A�/ J <br /> v�K 7-NAA/5PbR/�r'AT-/0%� // gDln< ��y1/SC7N 9W) Y66-ov�� <br /> ADDRESS <br /> � �D/2r/�/� 9Tf 57ZL^,t'.r0�/ c5 f9520 <br /> J 3 OBJ L srnEEr cm couxry ap <br /> �y CR STREET '` �/� TVPEOFAREA O COMMERCIALE:]INDUSTRIAL O RURAL TYPEOFBUSINES O RETAIL FUELSTATION <br /> Iv y /1✓ Q RESIDENTIAL Q OTHER Q FARM OTHER <br /> LOC AG NCV �1 AGENCY NAME CONTACTPERSON PHONE <br /> L 5 _ ETA D ( I <br /> yµ REG N ARD PHONE <br /> i NAME QUANTITY LOST(GAL ) <br /> 1 \ I �G �L _ - - UNKNOWN <br /> 5$2 � U cJ <br /> O UNKNOWN <br /> D/ATTEDISCOVERED ^T y/'� HOWDI )V RED O INVENTORY CONTROL SUBSURFACEMONITORMIG Q NUISANCEOONDMONS <br /> �o vD •�v v TANK TEST Q TANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLV) <br /> > UNKNOWN REMOVE CONTENTS O REPLACETANK CLOSETANK <br /> ww M M D 0 Y V <br /> HASDISC BEEN STOPPED? ,,J/- y/�7 ❑ REPAIR TANK REPAIRPIPNG CHANGEPROCEDURE <br /> Q YES 0 NO EYES,DATE OM / M /D �D Vr v OTHER <br /> wy SOURCE OF DISCHARGE TANKS ONLYA:APACI MATERIAL CAUSE(S) <br /> O ?MIK LEAK UNKNOWN IT GAL 0 F 14GLASS O OVERFILL a RUPTUREFAILURE <br /> PIPING LEAK AGE YRS Lr�/STEEL 0 CORROSION VuNKNOWN <br /> O OTHER Jv UNKNOWN Q OTHER 0 SPILL Q OTHER <br /> iw CHECK ON NLV <br /> UNDETERMINED O SOILONLY O GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> D% ❑ NOACTIONTAKEN 0 POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 <br /> ❑ CAP SITE(CD) a EXCAVATE&DEPOSE(ED) Q REMOVE FREE PROOUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> wcjCONTAINMENT BARRIER(CB) O EXCAVATES TREAT(ET) O PUMPS TREAT GROUNDWATER(OT) O REPLACE SUPPLY(RS) <br /> a <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA) O OTHER(07) <br /> t ED A,T, Ae uSlp S Co <br /> K k�rn6vAt_. V/3���. FlJ)ery�R 9.ry 45Sessrn6vT IVIL.L- /9E <br /> At EQU/k�D �f/E NR77146 ftND EXT�-T/7 eeYUl M(N <br /> K9DOSIA'&)) <br /> a- I <br />