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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT 1 HAVE <br /> ❑ <br /> YES NO EYES NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180,1 OF <br /> REPORTDATE CASES THE HEAL FDS YCODE / / <br /> qw— <br /> u �/o v O v SIGNEO MTE <br /> NAM OFINDIVIDUAL FILING REPORT PHONE SIGNATOR <br /> f nor, (Nf)ZED C <br /> q REPRESENTING O OWNEWOPERATOR ❑ REGIONALBOARDPIWYOR AGE CY NAME <br /> ;64 im <br /> LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> ET CRY f STATE ?C P <br /> NAMECONTACTPERSON PHONE <br /> ❑ UNKNOWN <br /> <y ADDRESS <br /> w <br /> STRE CRr ce,%V 6A, SPATE P <br /> FACLTIY AME(IFAPPUCAELE) OPERATOR PHONE pp1/rr// yy <br /> yr ( ) <br /> a ADDRESS <br /> ii L% Er L m '57VIC44701VQ <br /> mCROSS STREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> �17 REStDENTIAL. ❑OTHER ❑ FARM OTHER tSgto G <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w <br /> / lif ( 7 <br /> w!�A REGIONAL BOARD PHONE <br /> aY U O ) <br /> N <br /> I1) NAME OUANTRY LOST(GALLONS) <br /> UNKNOWN <br /> m3 ❑ UNKNOWN <br /> DATE MDISCOVER oo Dr Dy �i.�rNKTEST F-1 TANK REMOVWDISCOVERED INVENTORY�M ❑ OROL THER MONITORING ❑ NUISANCE CONDITgNS <br /> IDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u u P o v y � UNKNOWN REMOVE CONTENTS E] REPLACETANK ❑ CLOSETANK <br /> O HA❑SCHARGE KNO FYES,DATE M M D o r r ❑BEEN STOPPED? REPARTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES <br /> H SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> 4 ❑ TANKLEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUEFALURE <br /> c� ❑ PIPING LEAK AGE YRS KI STEEL ❑ CORROSKMI UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> yw CHECK ONE ONLY <br /> Njf: 54 UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zm <br /> zi ❑ SITE INVESTIGATION IN PROGRESS(DEFINNG EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETEDOR UNNECESSARY) <br /> VH NOACTK)NTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> 0 <br /> ❑ CAP SITE(CO) EXCAVATE B DEPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ft� ❑ CONTAINMENT BARRIER ICE) ❑ EXCAVATE B TREAT(ET) ❑ PUMPA TREAT GROUNDWATER(GT) a REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP CNN ❑ NO ACTION REWIRED(NA) ❑ OTHER ron <br /> T*NK "077PV-) 7t lg Vre&r ('zlrz�Zlzlo aorwit4--- oA7lo/,� <br /> !ot <br /> VW, � -ro yu6M/ra�u� ft*r44 �VFo <br /> i o i oLi�o h b e <br /> � mi ✓le VDon "-mov 0 "a`°�`N <br /> o <br />