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90- u 3� <br /> UNDERG UND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGEW SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORTREENFLED7I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> YES NO VE9 Q NO .REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASES THE HEALTH AN ,SAFTY CODE. <br /> 6, 4OM 3. .4 / D / r O Y SIGNED �— [ATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ) Yoe-.30 <br /> REPRESE a OWNEROPERATOR Q REGKNULBOARD COMPANY OR AGENCY NAME <br /> pµ LOCALAGENCY a OTHER �'Fy-yrj <br /> ADDRESS/`- <br /> /�/l G� iL �w f//�!✓� ��DI.E�nn G9- PSvZIP <br /> (ffr ATE <br /> NAME CONTACTPERSON PHONE <br /> w ao- . -s Q Q UNKNOWN <br /> ADDRESS <br /> �foc�Eycz CEap <br /> /f 95olUy <br /> FACILITY NAME(F APPLICABLE) OPERATOR PHONE <br /> nla";Fu rc� (?off) `/bG o37Y <br /> ADDRESS <br /> 115A9 c,E Al -5'n� ��r+�.� $�7 Sy <br /> CROSS STREET TYPE m ap <br /> OF AREA COMMERCIAL I]INDUSTRIAL Q RURAL TYPE OF BUSINESS a RETAILFUELSTATION <br /> C f/G Q RESIDENTIAL Q OTHER Q FARM Q OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> 12 <br /> ;{) REGIONAL BOARD PHONE <br /> i ( ) <br /> (T) NAME OUANTTTY LOST(GALLONS) <br /> m <br /> O O UNKNOWN <br /> (2) <br /> UNKNOWN <br /> t DATE DISCOVE D HOWOISCOVERED NTORY CONTROL D SUBSURFACE MONITORINGQ NUISANCE CONDITIONSG7 Ml 3 mi OD D !p Y DY 0 TAWKTEST EWrTANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Ml DI ol yl Yl UNIIWOWN a REMOVECONTENTS a REPLACE TANK a CLOSETANK <br /> HAS DIE BEEN STOPPED t i1 R TANK O REPAIR PIPING CHANGE PROCEDURE <br /> VES NO IF YES,D TE M w D D v v O1HER L(,-(7 NHa r✓f'— <br /> u� SOURCE OF DISCHARGE TANKS ONLY.CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK UNCNONN /COO GAL. a FI SE OVERFILLiFiFALURE <br /> ❑ PIPING LEAK AGE <br /> UNKNOWYRS STEEL a CORROSION UNKNOWN <br /> F-1 OTHER N a OTHER a SPILL a OTHER <br /> ywy�D CRECKONEONLY <br /> KZL a UNDETERMINED SOIL ONLY a GROUNDWATER a DRINKNGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON'-ONLY <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) a CLEANUP IN PROGRESS a SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) O <br /> �y a NOACTIONTAKEN a POST CLEANUP MONITORING IN PROGRESS a NO FUNDS AVAILABLE TO PROCEED a EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> wCAP SITE(CD) a EXCAVATE A DISPOSE(ED) REMOVE FREE PRODUCT(FP) a ENHANCED SO DEGRADATION(In <br /> K� CONTAINMENT BARRIER(CB) a E%CAVATEa TREAT(ET) PUMPB TREAT GROUNDWATER(Ona REPLACE SUPPLY(fly) <br /> a TREATMENT AT HOOKUP(HU) a NO ACTION REQUIRED(NA) a OTHER(OT) <br /> 're sSe,sx .c w.// szLcessa+ -Ao alc.�GrMYwL <br /> & eX/eiA-y of c®nd1ti.,,... +an 93L-s rltfi'A. <br /> u/sE±i -- n c <br /> rwcasluA <br />