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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FORLOCALAGENCY USE ONLY <br /> REPORT BEEN FLED 4 I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT HAVE <br /> ❑ YES ❑ NO ❑YES ❑ REPORTED T IFORMATION T0; AL OFFICIALS PURSUANT/TO SECTION 251007 OF <br /> REPORTDATE CASE4 THEHEALTHAN.0 YCODE' f n <br /> �-'f---/-wf l F <br /> GM �/jMO Y <br /> l I SIGNED F DATE <br /> IS <br /> NAME OF INDIVIDUAL FLING REPORT PHONE � y SIGNA <br /> REPRESENT ❑ OWNEWOPERATOR ❑ REGIONALBOARD COMPANY OORAGENCY INN <br /> OCAL AGENCY OTHER �j /✓ C/��[/�< <-�/ ®/�� <br /> ADDRESS <br /> p2 5 qTY STATE 2P <br /> NAME CONTACTPERSON PHONE <br /> ' ADDRESSv/f^� ElUNKNOWN <br /> 1,9 D <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> I ( ) <br /> ADDRESS <br /> �O <br /> Drtv PE OF BUSINESS <br /> CROSS STREET TYPE OF AREA MERCIAL ❑WDUSTRIAL❑RURAL RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM THER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> REGIONAL BOARD PHONE <br /> I ( <br /> (1) NAME OUANTITY LOST(GALLONS) <br /> y /L EP�NOWN <br /> $� (2) <br /> ❑ UNKNOWN <br /> DATE DISCOVERED J� HOWDISCOVERED ❑ IN VE RY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> I OM Ald-M D D 4 Y Y ❑ TAW TEST ANC REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D r Y �UNIQJOWN E-] REMOVECONTENTS ❑ REPLACE TANK OSE TANK <br /> HASDISC GE BEEN STOPPED � REPAIRTANK O REPAIRPPNG O CHANGE PROCEDURE <br /> YES O NO FYES,DATE M .1 DI al YJ Y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYrAPACITY MATERIAL ��555GGGGG��LLLAAASSS CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN .�OO COL. ❑❑ F�S O OVERFILL ❑ RUPTUREFALURE <br /> O PIPINGLEAK AGE YRS STEEL ❑ CORROSIONUNKNOWN <br /> ❑ OTHER NKNDWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECKONEONLY <br /> O UNDETERMINED SOIL ONLY a GROUNDWATER O DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLFANAUP COMPLETED OR UNNECESSARY) <br /> UN ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4z ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 0o <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PU TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP 6M ❑ NO ACTION REQUIRED INA) OTHER(I eLCi _ <br /> %9�✓✓E ,Pa md✓gG yr L 1?esal& /eveAf L'vh7l�pnii/a/l t. . r •2.�`. si <br /> .9sSinp,�j tJiL� Q�iQU�2�b T 0&4�Pi2 .v�I./ <br /> Gra-.te 04 <br /> McD�lNml <br />