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-rl-1 <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 NO REPORT BEEN FILED? OYES � NO I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> �J REPOR4944R9 <br /> ANT TO SECTION 25180.7 OF <br /> REPORT <br /> DATE �( CASE# THE HEOM vu 71 o �Y r SIGNED k� ATE - <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> REPRESENTING ❑ OWNEPAWERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY [:j OTHER <br /> A KESSAff0l (/'y[ <br /> `ir/✓ CRY 6•` WATE ` ZIP <br /> MJ <br /> NAME OCNTACTPERSON PHONE <br /> 4v o ❑ UNKNOWN gyrIF— Vey 6 <br /> y ADDRESS <br /> 6-17 K 9TREEf ( CITY ovc WATE %o p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR pHpNE <br /> s — o Cv �fNlfD �1 rho1 <br /> i ADDRESS <br /> CAtai <br /> y GROSS STREET TIDE OF AREA crtv aoutRr p <br /> COMMERCIAL Q INDUSTRIAL O RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> r� ❑RESIDENTIAL Q OTHER [::] FARM OTHER <br /> LOCALAGENCY AGENCY NAM CON ACT PERSON PHONE <br /> uI;L REGIONAL BOARD <br /> S Y PHONE v <br /> y (LI NAME OUANTRY LOST(GALLONS) <br /> UNKNOWN <br /> ❑ UNKNOWN <br /> DATEDISCOVERED G HOWDISCOVERED O INVENTORYCONTROL ❑ SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> u o Z� v / r TANK TEST TANK REMOVAL OTHER <br /> TE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o r Y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPWG ❑ CHANGEPROCEDURE <br /> S YES ❑ NO FYES,DATEM Z,61 flY Y ❑ OTHER <br /> M _ <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> q ❑ TANK LEAK QI UNKNOWN !C600 GAL, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION ® UNKNOWN <br /> ❑ OTHER XT UNKNOWN OTHER O SPILL ❑ OTHER <br /> ww CHECKONEONLY <br /> a <br /> U� UNDETERMINED O SOILONLY O GROUNDWATER O DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> rg CHECK ONE ONLY <br /> 6 ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CS) EXCAVATE&TREAT(ET) ❑ PUMP&TREATGROUNDWATER(GT) ❑ REPLACESUPPLY(RS) <br /> ❑ TREATMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) O OTHER(01) <br /> &5-WaW <br /> w ut4zz� u � T c g7; Ko fiZiP. <br /> ai <br /> K&C06(WI <br />