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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGEN SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES ,� REPORT BEEN FLED? YES Q NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> Lp NO REPORTED THIS INFORMATION T0.LOCAL OFFICIALS PURSUANT TO SECTION 25160.7 OF <br /> R//E�PP1ORTDATE /_ J((] 9 CASE C< THE HEALTH AND <br /> /c"�^OM�OE r y74� <br /> '._/M 3M D lU V y / y �. •l.'aLdL� iG. _ l C <br /> NAME OF INDIVIDUAL FLING REPORT PHONE MM"DD II SIGNATURE <br /> Res c-,4, (c6q)-6¢-3'fyI <br /> 0 REPRESENTING O OWNEWOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY E / � - /� � � ��[� <br /> O &LOCALAGENCY D OTHER C�Q�n� �0(1 CQGcx,40A �L,�I� A (C <br /> a <br /> ADDRESS <br /> 1 lD d s ReET c ry eR TE <br /> NAME CONTACTPERSON PHONE <br /> N� FOR 14N K S � o✓a"flucK: � UNKNOWN K[/S � o �o P40V65 ?15 <br /> a ADDRESS ro Q W {L �� �p <br /> iofi N 8 d w Sf�G SAE �`;P 7 <br /> FACLITY NAME(E APPLICABLq OPERATOR /J PHONE <br /> �r 1`h G i ).,:-r 4'r 9jo. h D/o <br /> ADDRESS <br /> /0 /I Bros S toc,f a,�. CA �Sao� <br /> Clf'/ (XXINTY <br /> CROS RE//� TYPE OF AREA O COMMERCIAL Q INDUSTRULL Q RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> 0 RESIDENTIAL 0 OTHER Q FARM O OTHER <br /> LOCALAGENCV AGENO L' ODNTACTPERSON PHONE <br /> REGIONAL BOARD PHONE <br /> C W Q ( ) <br /> (1) NAME OUANTTTY LOST(GALLONS) <br /> 'Die s�l .�,, ( Q UNKNOWN <br /> (a <br /> I <br /> a (� / UNKNOWN <br /> ` ml DISCOVERED <br /> M,'^o �0 8 v (py HOWO013COVERED INVENTORY EMOCONTROL O OTHER MONITORING <br /> Q NUISANCE CONDMONS <br /> TANK TEST ANC REMOVAL <br /> DATE DISCHARGE BEGAN �� , METHOD D TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> M M D D Y y LJ UNKNOWN REMOVE CONTENTS O REPLACE TANK �CLOSETMM <br /> HAS DISC ❑BEEN STOPPED? /M �M ODD (�y �" O OTHER REPAIRTANK O REPAIRPIPING CHANGE PROCEDURE <br /> p VES NO EYES,GATE 0 0 <br /> Y <br /> u� SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> 0 TANKLEAC EO/UNKNOWN GAL. Q FIBERGLASS O OVERFLL O RUPTUREFALURE <br /> PIPINGLEAK AGE YRS STEEL CORROSION UNKNOWN <br /> OTHER O UNKNOWN Q OTHER 0 SPILL 0 OTHER <br /> CHECKONEONLV <br /> B� E UNDETERMINED O SOILONLY a GROUNDWATER Q DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKON NLY <br /> N <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) [_j CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> O NOACTIONTAKEN Q POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVALA13LE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 F-1 CAP SITE(CD) ❑ EXCAVATE&DISPOSE(EM Ej REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(11) <br /> X$j ❑ CONTAINMENT BARRIER(CS) O EXCAVATE&TREAT LET) PUMP&TREAT GROUNDWATER(G-D O REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) O NO ACTON REQUIRED INA) 0 OTHER(07) <br /> Fr'le revrecv a-pteL-Ims c,fi•aY,� reveal. (ed <br /> A -1'cvrK I b160 p /mss ' Jr��2aL-ace�w <br /> be-4'v+ J fil will b� <br /> a , ,u, vri, a 4 <br />