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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SE RVICES <br /> REFORTBEEN FILED? FOR LOCAL AGENCY USE - <br /> ❑ VES AM <br /> NO ❑YES ❑ NO REPORTED THIS INFORMATII HEREBY CERTIFY THAT I AM ON TO LOCAL OFFICIALS PURSUANT TED GOVERNMENT TO SECTION 251807YEE AND THAT I AVE <br /> OF <br /> REPORTDATE CASE# THE HtEALTH AfNuD SAFTY CODE. L <br /> dM M s Sl-C RC1.. /,P✓ .J I I �- Y/� (�� <br /> Y Y SIGNED DATE I_ <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> a�sd GQr1s (209) kb€-3va � <br /> REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY F--1OTHER L� <br /> ADDRESS "� Vo4 �M Lo Lei [ c, It E., <br /> WATE <br /> NAME /' 1 ^ COONTACTPER1SON PPHONE b 1O, /T'L_ )� ❑ UNKNOWN ()f_ 6. `JVt <br /> n ADDRESS <br /> P. 0, �,Z;e ro! ✓q c—A lis-39TREEf <br /> FACILITY NAME(E APPLICABLE) STATE <br /> /' � OPERATOR <br /> PHONE <br /> ADDRES <br /> FSw ¢_)TCar..-�..cT..✓'�.. `--w �. ,C� tt I i, (�4) SSb^L240 <br /> S, JuCj, <br /> .9 T <br /> TV TS _ I1��BTREEf��• \✓1C !-1 •13 <br /> 55 CROSSSTREET TYPEOFAREA O �NDUSTRUIL RURAL TYPEOFBUSINESSKfY/ <br /> COMMERCIAL ❑ ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> P:89 So <br /> REGIONALZRD 1 ' 1 <br /> a t Ce,.TA„_( U cAPHONE <br /> f?lr, )3Ct — S'coo <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> O 1 <br /> c\v a�2tJ,e.� �,.e moo,✓�.n UNMOWN <br /> [SdUNCNOWN <br /> w <br /> DATEDISCOVERED G HOW DISCOVERED SOI INVENTORY CONTROL ❑ SUBSURFACEMONITORNO ❑ NUISANCE CONDRK)NS <br /> M b M t o ro ' v �r ❑ TAMC TEST (�J TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> M u o o v r UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPIPNG CHANGE PROCEDURE <br /> p YES ❑ NO IFYES,DATE ( u OM ( p So F-1 (P r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYrOAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK w UNKNOWN (S_y� GAL, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS ❑ STEEL <br /> ❑ CORROSION UNKNOWN <br /> ❑ OTHER 19UNKNOWN ❑ OTHER ❑ SPILL O OTHER <br /> w� CHECKONEONLV <br /> u� ❑ UNDETERMINED SOIL ONLY 0 GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> zm <br /> i ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 8° NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> C 4EC K APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o ❑ CAPSITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(11) <br /> ca ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMPA TREAT GROUNDWATER(GT) ❑ REPLACESUPPLY(RS) <br /> /❑' <br /> TREATMENT AT1HOOKUP(HU) 1 ❑ NO ACTION REOUIRED INA) ❑ OTHER(OT) 1 <br /> (^q,�\s,.�TN.��iu,.. ,.,.e-{GP e,.iia.y `+\� ✓t,.,.,.v,\. G.tr. U,.�cd -E.",.T�,.i r� 0.-t <br /> -ky_Cqv <br /> 8 <br /> 118C OS(AV) <br />