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�a ori <br />C7 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />REPORT BEEN FILED 7 <br />❑ VES TLO [::]YES ❑ NO <br />I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />'REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />IHIE H <br />REPORTDATE CASE• <br />oml I MI Id 414 c?Yl OY <br />SIGNE DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />a <br />REPRE NTING F-1OWNEIVOPERATOR F—]REGIONALBOARD <br />COMPANY OR AGENCY NAME <br />¢O <br />LOCAL AGENCY ❑ OTHER <br />a <br />ADDRESS <br />eET CRY STATE o ZIP <br />ME <br />CONTACT PERSON PHONE <br />hVmNs <br />❑ aaKNowN <br />'�q �n7tw (20') - <br />y <br />ADDRESS <br />Ip <br />q5;?06 <br />¢chltoq <br />STREET (��N CRY STATE IIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />Ca m Y <br />)207) ?W- W6 <br />ADDRESS <br />w , <br />STREET I`V cm /� CWNTY D� ap <br />ySSTREET <br />TYPE OF BUSINESS <br />TYPE OF AREA COMMERCIAL ❑ INDUSTRIAL ❑ RU RETAIL FUEL STATION <br />❑ RESIDENTIAL ❑ OTHER ❑FARM THER <br />i <br />LOCALAGENCY AGENCY NAME <br />CONTACTPERSON <br />PHONE <br />68'-3f� <br />_ � <br />N uiA. R+6 � �r/l�iQs <br />tit <br />� ► <br />w <br />REGIONAL BO RD <br />PHONE <br />( ) <br />a <br />I1) NAME QUANTITY LOST (GALLONS) <br />q <br />i <br />_ <br />❑ UNKNOWN <br />6 0x.6 //� <br />( 2)iT+".� <br />y- <br />❑ UNKNOWN <br />i <br />DATEDISCOVERED <br />HOWDISCOVERED ❑ INVENTORY CONTROL E:]SUBSURFACE MONITORING E::]NUISANCE CONDITIONS <br />❑ TANKTEST TANK REMOVAL ❑ OTHER <br />2 <br />M M o o Y r <br />DATEDI HARG BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL`O <br />a/UNKNOWN <br />❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br />p <br />Y <br />❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br />HASDI HARGE BEEN STOPPED? <br />p <br />?YES ❑ NO IFYES,DATE M M o Di r Y <br />❑ OTHER <br />H <br />SOURCE OF DISCHARGE <br />TANKS ONLYrAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANKLEAK UNKNOWN <br />1QT—GAL- ❑ FIBERGLASS <br />❑ OVERFILL UPTUREIFAILURE <br />vuNKNOWN <br />F-1PIPINGLEAK <br />AGE 1—YRS STEEL <br />❑ CORROSION <br />❑ OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w� <br />CHECKONEONLY <br />HAVE ACTUALLY BEEN AFFECTED) <br />❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER(CHECK ONLY IF WATER WELLS <br />CHECKONEONLY <br />gg <br />c< <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />m <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS E]NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />b❑ <br />CAP SITE (CD) ❑ EXCAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />w <br />❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE B TREAT (ET) ❑ PUMPA TRFAT GROUNDWATER (GT) E]REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (14U) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OI) <br />ja -k Rtmona l-s$/Tl t n�u/f& owls so./ <br />ten, <br />"'� HUNGje hILT1YK/'E 4/.0� �J%ie-� fa.M1A.t.�t 1L/d,r1J <br />u�7 <br />Lull%46ef�NI� �/ 4Y7T/ <br />as r�jair�/ tie a��ofryaGt rFgG/ ,kjn e:vs <br />I <br />