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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES REPORT BEEN FLED7 D YFS D NO I HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS FORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25100,7 OF <br /> REPORT DATE CASE# THE HE AFTY CODE: <br /> UM D �Y Y <br /> L slcNEo 2G <br /> NAME OF INDIVIDUAL FLING REPORT E <br /> PHONE SIGNATURE <br /> P-3 <br /> w REPRESENTI OWNEWOPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> u AGENCY D OTHER ' <br /> s ADDRESS <br /> /"�j <br /> NAME crry "ATE x#• <br /> OONTACTPERSCN PHONE <br /> zgezp /��y <br /> m� UNIPIOWN I ) O 2-- 5/ <br /> i ADDRESS <br /> a7 96p STREET i i . CRV SAE 7rS33p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR pFp <br /> NE <br /> ADDRESS GV7) MIS! <br /> i <br /> � f.3333C� <br /> kl STREET cm <br /> 40UKTY <br /> as CROSS STREET TVPE OF AREA O COMMERCIAL D WDUSTRLLL RURAL PE OF BUSINESS &d9 ap <br /> TAIL FUEL STATION <br /> O RESIDENTIAL O OTHER D FARM ER <br /> g LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Xym <br /> itL iiL,+l ��3 S <br /> REGION ARD (Zdr) <br /> PHONE <br /> NAME QUANTITY LOST( <br /> NKNOWN <br /> k DATEDISCOVERED I HOWD13WVERED O INVENTORY CONTROL E] SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> M oi (ool y D TANKTESTTANK REMOVAL D OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ft�s?!Ej <br /> D D Y y UNKNOWN D REMOVECONTENTS D REPLACETANK O CLOSE TANK <br /> HABEEN STOPPED 0 I— RREPAIR TANKS__— +D REPAIR PIPING D CHANGE PROCEDURE <br /> p NO IFYES,DATE M ml .1 D Y y P —�R Ar-n '"� z6wjL <br /> �i SOURCE OF DISCHARGE TANKS ONLY,CAPACITY MATERIA. CAUSE(S) <br /> D TANK LEA( UNKNOWN 90 GAL O FIBERGLASS D OVERFILL D RUPTUREIFALURE <br /> D PIPINGLEAK AGE YRS F2 STEEL CORROSION UNKNOWN <br /> D OTHEfl1NKNONM D OTHER D SPILL D OTHER <br /> w lu CHECK ONE ONLY <br /> D UNDETERMINED SOILONLY D GROUNDWATER D DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> ¢< D INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEIq D CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NOACTIONTAKEN D POST CLEANUP MONITORING IN PROGRESS D NO FUNDS AVAILABLE TO PROCEED D EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> D CAPSITE(CD) D EXCAVATE&DISPOSE(ED) D REMOVE FREE PRODUCT(FP) D ENHANCED BIO DEGRADATION QT) <br /> D CONTAINMENT 13APIRIER(CS) D EXCAVATE&TREAT(ET) D PUMP&TREAT GROUNDWATER(GT) D REPLACE SUPPLY IRS) <br /> O <br /> TREATMENT AT HOOKUP(H4 O NO ACTION REQUIRED INA) L2--O'THER(OT) �,L.(/j <br /> �' ✓.�u'LT / c GC 1.09�T .t'.✓ A-1 TA <br /> fir (-�,� � <br /> SCM' ) <br />