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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />❑ YES OZ/NO <br />L✓JN / REPORT BEEN FOILED? ❑ YES O NO <br />''� <br />MENT EMPLOYEE AND THAT I HVE <br />CERTIFY THAT I AMATO LOCAL LSN AOF <br />REPPORTED <br />REPORTED 5 NFORMATIONHEREBY <br />OFFICIAIGNATED <br />PURSUANT O SECTION 25180.7A <br />THE HEALTH AN`O SAFTY CODE <br />REPORT DATE CASE# <br />p <br />/.10.1 / 9'Y <br />SIGNED SATE <br />.30,Y <br />NAME OF INDIVIDUAL FLING REPORT <br />PHONE <br />SIGNATURE <br />(2oz-- <br />I Pov)y(oa <br />ro/ <br />REPRESE O OWNERIWERATOR ❑ REGIONALSOARD <br />COMPANY OR AGENCY NAME <br />n <br />LCOALAGENCY OTHER <br />at?T.�u ee flub /e yC ///1 S w <br />m <br />ADDRESS <br />o/ �= /1 fZ7/7 0ZIP <br />n.7 /� CITY %vc/C SPATE <br />NAME <br />CONTACTPERSON PHONE �I/, <br />m <br />©e//h rptCor #33 ❑ UNKNOWN <br />//� <br />-2-01 FUrr ) �(o�- � 3 <br />�n <br />SWi <br />5 <br />ADDRESS <br />�i 7/'(A " <br />F. rm?er 5kc- -1w1% <br />_ BTREET CT' SPATE (_%i <br />FACILITY NAME IFAPPLICABLE) <br />OPERATOR PHONE err 3YO <br />Co.' -/o 3 3 <br />To r) Fu i -e- d1) Y& /- yo 93 <br />4 <br />25 <br />ADDRESS At, <br />�'4s <br />Aix • <br />/ e .7'x/7 cau q.SO <br />y <br />CROSSSTREET <br />TYPE OF AREA OOOMMERCIAL NDUSTRIAL Q RURAL <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />.4-77,1 A- 7 � <br />[:]RESIDENTIAL Q OTHER <br />0 FARM ER <br />LOCALAGENCY AGENCY NAME sC%"✓wKCi <br />OONTACTPERSON <br />PHONE <br />�9)Y68-3V&J/ <br />wW, <br />REGIONAL BOARD <br />PHONE <br />cle A> CB <br />6v'-wo/7 3o el c7 -s <br />( ) <br />w <br />(11 NAME OUANTRYLOST� ) <br />e o Q UPS <br />(2) <br />&17 <br />n r f, -W Eg KKNOWN <br />i <br />DATEDISCOVERED <br />HOWDISCOVERED n INyENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br />w <br />M u D D Y v <br />LL9 '!� <br />� TANK TEST TAW REMOVAL O OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISOHARGE(CHECK ALL THAT APPLY) / <br />LL�uu <br />u u D D r v UJIWOWN <br />0 REMOVECONTENTS O REPLACE TANK CLOSETANK <br />fi <br />HAS DISCHARGE BEEN STOPPED 7 <br />L] REPAIRTANK REPAIRPPNG CHANGEPROCEDURE <br />p <br />YES D NO FYES,DATE <br />❑ OTHER <br />M M DI D Y Y <br />u� <br />SOURCE OF DISCHARGE <br />TANKS ONLYCAPACITY MATERIAL <br />CAUSES) <br />O TANKLEAK UNKNOWN <br />/0/4r—.GAL 0 FIBERGLASS <br />0 OVERFILL 0 FLP AZURE <br />PIPINGLEAK <br />AGE YRS O STEEL <br />O CORROSION UNKNOWN <br />O OTHER <br />NKNONM Q OTHER <br />O SPILL 0 OTHER <br />w <br />CHECKONEONLY <br />Q UNDETERMINED SOIL ONLY O GROUNDWATER O DRINKINGWATER.(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECK ONE ONLY <br />z# <br />i <br />O SITE NVESTIGATION IN PROGRESS (DEFINN6 EXTENT OF PROBLEM) Ej CLEANUP IN PROGRESS Q SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />v°1 <br />NO ACTION TAKEN � POSTCLEANUPMONITORWGINPROGRESS Q NO FUNDS AVALABLETO PROCEED EVALUATINOCLEANLP ALTERNATNES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />i5 3 <br />❑ CAP SITE (CO) El EXCAVATE 6 DISPOSE (ED) REMOVE FREE PRODUCT (FP) Q ENHANCED BIO DEGRADATION (IT) <br />¢� <br />CONTAINMENT BARRIER IDS) O EXCAVATE& TREAT (ET) O PUMP& TREAT GROUNDWATER (G1) O REPLACESUPPLY(RS) <br />TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED INA) O OTHER (07) <br />Gr r��/�eY s i,(� assns ��/C�ui/Y� �o a(t{lii.»//•(a nafic.e %'L tyT�r/& <br />/�Cr/sus <br />HSC M(d9]) <br />gCl- �3.,7 <br />!— <br />