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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SER VICES/ <br />FOR LOCALAGENCY USE ONLY <br />0 YES NO REPORT BEEN FILED 7 O YES '� <br />I HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />L9 <br />REPORTED THIS INFORMATION TO LOCAL OFFICIALS. PURSUANT TO SECTION 25100.7 OF <br />THEHEALTHANDSAFfYCODE <br />REPORTDATE CASE$ <br />�u G <br />SGNEO RATE <br />r v <br />NAME OF INDIVIDUAL FLING REPORT <br />PHONE <br />SIGNATURE <br />�i <br />z— <br />tai) y68'-34 39 <br />REPRESENTING OWNERIOPERATOR Q REGIONALBOARD <br />COMPANY OR AGENCY NAME �GC(71Y0h �I�`i"4 <br />p <br />LOCAL AGENCY OTHER <br />ai��0& .tin Loc -ems k f <br />,S z <br />ADDRESS <br />/� I s ^ �.J <br />v/ -z 1 -foo? s�. �L/C <br />GTr �1 BtATE �"1 zip <br />NAME <br />CONTACTPERSON PHONE <br />iQ <br />\- ,.y� <br />�p I //� n _ ❑ UNKNOWN <br />oc <br />E y <br />ADDRESS <br />CITY V-4STATE P <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />/ # 33 <br />a (d" L[ - 0 <br />ADDRESS <br />s ao <br />- <br />IF, /-77 , <br />as <br />CROSSSTREET <br />TYPEOFAREA COMMERCNL INDUSTRIAL RURAL <br />TYPE OF BUSINESS Q RETAIL <br />/ <br />- T �� <br />Q RESIDENTIAL Q OTHER <br />O FARM 02OTZ <br />i <br />LOCALAGENCY AGENCY NAME <br />CONTACTPERSON <br />PHONE <br />iC <br />a -�I ✓ Z <br />�{N/)�`� SY3 <br />Iy yi <br />REGIONAL BOARD <br />PHONE <br />NAME QUANTITY LOST(ON-LONS) <br />2 Imo- WNOWN <br />(2) <br />T UN(NOWN <br />t <br />DATE DISCOVERED <br />HOW DISCOVERED O pNTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br />!/v <br />TANK TEST L16 TANK REMOVAL a OTHER n,ts ci /n 4r <br />I <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL TWLT APPLY) <br />F'��/-, <br />M u o y r �I '^'AWN <br />Q REMOVECONTENTS O REPLACE TANK Q CLOSE TANK <br />DISCHARGE BEEN STOPPED 7 <br />QHAS <br />REPAIRTANK O REPAIRPPNG CHANGEPROCEDURE <br />p <br />F-1 YES E::] NO FYES,DATE <br />OTHER <br />M M o ol v Y <br />y <br />SOURCE DISCHARGE <br />TANKS ONLY,CAPACITY MATERIAL <br />CAUSE(3) <br />,4$O <br />TANKLEAK 0 UNKNOWN <br />-!9 9 ()IOL, Q FIBERGLASS <br />Y' <br />O OVERFILL O RUP AIUURE <br />¢ <br />PIPINGLEAK <br />AGE YRS EL <br />CORROSION UM(NOWN <br />( O O R <br />E% -TW Q OTHER <br />O SPILL O OTHER _ <br />yw <br />CHECK EONLY <br />t3� <br />UNDETERMINED O SOILONLY O GROUNDWATER O DRINKINGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />f <br />CHECK EONLY <br />¢< <br />SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) 0 CLEANUPINPROGRESSO SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />t3y <br />❑ NOACTIONTAKEN 0 POST CLEANUP MONITORING N PROGRESS NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATNES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />CAP SITE(CD) O EXCAVATE& DISPOSE (ED) E] REMOVE FREE PRODUCT(FP) E:] ENHANCEDBIODEGRADATION(IT) <br />7 CONTAINMENT BARRIER (CB) a EXCAVATE& TREAT(ET) PUMP& TREAT GROUNDWATER (GT) O REPLACESUPPLY(RS) <br />O TREATMENTATHOOKUP({AN) O NOACTIONREOUIRED(NA) O OTHER(OT) <br />!a <br />4 <br />