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FA <br />UNUthUhUUNU J I UNAUt I ANTI UNAU I hIJh1LtU HtLtASt (LtAF,) / GUN I AMINA I IUN JI I It h(tt-uh 1 <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FORLOCALAGENCYUSEONLY <br />❑ <br />YES REPORT BEEN FILED? E] YES ❑ NO <br />REEREBY CERTIFY THAT I AM TED EMPLOYEEVERMENT <br />O SECTION 25100�AVE <br />PORTED THIS NFORMATION0.TDOES <br />FGCIALSN PURSUANT OF <br />THE HEALTH AND SAFTY CODE y <br />REPORT DATECASEi <br />IIY rY <br />SIGNED WTE <br />m <br />NAME OF/ INDIVIDUAL FLING REPORT <br />Wi11,I Q, SNAV <br />PHONE <br />( <br />SIGNATURE <br />� uN^- <br />REPRESENTING ❑ OWNER/OPERATOR ❑ GIONALBOARD <br />COMPANY OR AGENCY NAME <br />LOCAL AGENCY ❑ OTHER <br />S <br />¢ <br />ADDRESS po o <br />// /� <br />�I � <br />clrr arATe m <br />■ <br />NAME <br />CONTACTPERSON PHONE <br />ft-'7W-01 <br />UNKNOWN <br />v, I/ �� <br />3 <br />ADDRESS ---) ��/ <br />101 fo <br />S-7O�O � <br />`- ' �ap <br />/ BT , W <br />WY WATE <br />FACLITY NAME IF APPLICABLE)f <br />�JTaa-lvN <br />OPERATOR PHONE <br />6-782a <br />hwtjr&4 Ce- <br />¢099 <br />ADDRESS <br />ADDRESS lt <br />yCROSSSTREET <br />TYPE OF A4 MERCIAL❑ INDUSTRIAL RAL <br />TYPE OF BUSINESS ❑ RETALFUELSTATION <br />/- aR <br />G 4 /7 7Zt- <br />❑ RESIDENTIAL Q OTHER <br />❑ FARM Q OTHER <br />LOCAL AGENCY AGENCY NAME <br />— -T A <br />DONTACTPERSON <br />PHONE <br />c'11 5�d if 3�f� <br />N cAc. H )sr <br />W;y <br />Y <br />REGIONALBOARD <br />PHONE <br />06 <br />C v leliki 92 cle <br />NAME <br />(1)q - <br />QUANTITY LOST( GALLONS) <br />yq <br />wi <br />c <br />/7/QSa Li,�� <br />❑ Umomm <br />- <br />M <br />❑ UNKNOWN <br />k <br />DATEDISCOVERED (Jif, <br />/u u /DI <br />HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUSSURFACEMONRORNG ❑ NUISANCECONDITIONS <br />TANK TEST Q TANK REMOVAL Q OTHER <br />S <br />DATE DISCHARGE BEGAN <br />METiK)D USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />UNKNOWN <br />E]REMOVECONTENTS E:] REPLACE TAW ❑ CLOSE TANK <br />�y <br />M M D Y Y <br />HAS DISCHARGE BEEN STOPPED? <br />❑ REPAIR TANK ❑ REPAIRPPNG ❑ CHANGEPROCEDURE <br />-Q <br />❑ YES ❑ NO FYES.DATE u D D D Y r <br />❑ OTHER <br />u� <br />SOURCE OF DISCHARGE TANKS ONLYJCAPACITY <br />1 <br />MATERIAL CAUSES) <br />❑ TANKLEAK hwoi UNKNOWN � /JAL, <br />❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br />PIPINGLEAK AGE YRS <br />❑ STEEL CORROSION ❑ UNKNOWN <br />❑ OTHER ❑ UNKNOWN <br />❑ OTHER ❑ SPILL ❑ OTHER <br />w� <br />CNECK ONE ONLY <br />UNDETERMINED ❑ SOILONLY Q GROUNDWATER <br />O ORINKNG WATER ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />a <br />CHECK ONE ONLY <br />SIGNED OFF COMPLETED OR UNNECESSARY) <br />CANUPINPRQGRESSQ NE <br />F-]SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) E]IE <br />D, <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) <br />❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />3 <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE& TREAT(ET) <br />❑ PUMP& TREAT GROUNDWATER KYO REFACE SUPPLY (RS) <br />¢ <br />❑ TREATMENT AT HOOKUP(HUI ❑ NO ACTION REQUIRED (NA) <br />OTHER (01) <br />ece/ I✓ed rise 5 O / �i L ea! r e U S 7e5T O 70a <br />Cv i <br />Sri-e/ ,Autov <br />f�50s5ni c4w4-- i I I be re-a u <br />jraqAiAzs bX 4y,� 6Lp1r6prikk <br />aq <br />N MIIMT <br />FA <br />