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11. .PW <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES REPORTBEENFLED? ❑YES ND I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> .REPORTED THIS INFORMATION TO LOC L OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE4 THEHEAL AFfYGbDE c_�, �rI _ <br /> tL / <br /> Y Y SIGNED om DATE/ <br /> NAME OFWDIVIDUAL FLING REPORT PHONE UNATURE <br /> m /V/ <br /> q REPRESENCI ❑ OWNEggpERATOR ❑ REGIONALBOARD OOMPANYORAGENCY NAME <br /> p OCALAGENCY ❑ OTHER S � y� _� <br /> a [� <br /> ¢ ADDRESS /� <br /> / F / /V piY WAn ZIP <br /> NAME// <br /> / CONTACTPERSON PHONE <br /> /'/ T ❑ UNKNOWN <br /> ADDRESS <br /> S111 BTRELT 9M�crry224WATe �— * <br /> FACILITY NAME(F APPLICABLE) RATOR PHONE <br /> S .,TA� I <br /> ADDRESS <br /> yCROSSSTREET WIPE OF AREA EVwMERCIAL❑NOUSTRWL❑RURAL5 TYPE OF BUSINESS RETAIL RETAILFUELSTATDN <br /> [1]RESIDENTIAL ❑OTHER ❑ FARM ©'OTHER <br /> LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> W l / <br /> w REGIONAL BOARD PHONE <br /> a <br /> NAME OUANTRY LOST(�d—LL1LO�NS) <br /> CJ LN "NCNOWN <br /> P� ❑ UNKNOWN <br /> a DATEDISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING O NUISANCECONDITIONS <br /> i u (� D O Y y ❑ TANK TEST ICK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> MI M DI D1 Yl y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HAS DISC GE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IFYES,DATE MI MI DI DI Y �THER � �'� ?6E1wM�f1�/� <br /> u� SOURCE OF DISCHARGE TANKS ONLY1CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK NMCNOWN / D��� GAL. ❑ FIBE S O OVERFILL ❑ RUPTUREiFAILURE <br /> ¢ ❑ PIPING LEAK AGE YRS EL ❑ CORROSION LJ-10<KNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> yw� CHECKONEONLY <br /> �j� ❑ UNDETERMINED ❑ SOILONLY GROUNDWATER [:] DRINKING WATER- (CHECK ONLY F WATERWELLB HAVE ACNALLY BEEN AFFECTED) <br /> 1130 CHECKONEONLY <br /> ¢ ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F-1CLEANUPIN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 3% ❑ NOACTIONTAKEN ❑ POSTCLEANuPMONRORINGIN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAPSITE(CD) F7 EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BD DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMPB TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTON REOUIRED INA) O OTHER(OT)eeae aim T eui1,1_ j3G eeaurrtiW Tp ,0eir .y1tiEy , <br /> /} /D -xr 12 TiR�f!/U.¢r/Oa/� lfa6�� A t-f Olep_e/ 4�q me <br /> OD nscmiamn <br />