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ti, .,' <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY . <br /> ❑rE3NO REPORT BEEN FLED? EMPLOYEE AND THAT I <br /> ❑YES ❑ NO REPORTED THIS NFORMATIONHEREBY CERTIFY THAT I AMATO LOCAL OF MENT ICIALSDESIGNATEDNPURSUANT TO SECTION 251807AOF <br /> REPORT DATE (�( ry j, CASE# T E HEALTH AND SAFTY COOS <br /> oM SM O D Fl <br /> V U VN�Ec.�FC_ ✓i 0." �Yo ' 5�. ✓! tai✓!rb"'Qrl� <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING ❑ OWNER;OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> WLOCAL AGENCY ❑ OTHER �y �oA. v�y �ocL( Q��{.. DI ✓icl <br /> a ADDRESS <br /> Ie� l G , �4�c('�o'^���•o- �jo�r 2001 S��'b•, <<1' �lSLo/ <br /> 14 NAME CONTACTPERSON STATE p <br /> p } 1 i PHONE <br /> i� oL,,. IJE �1.. cc..r l ❑ UNKNOWN b, E W�•�\�^ <br /> a (2cPiT- 3S-0629 <br /> E n ADDRESS <br /> W �I131 1✓Yd s4✓ I (nia �RYS< < A 4S3�fo <br /> a BTREEi WATE mp <br /> FACILITY NAME(IF APPLICABLE) u OPERATOR PHONE <br /> z CaO SA C• ---�es Ex ✓mss p • - (.i 1 er (2d{) 835-0629 <br /> ADDRESS <br /> 4131 . � :� ,tI 4 ��-� C �S3 <br /> �Ay CIfY JgM�G u..� <br /> m C1ROSSSTREET (� 1 7NAMr <br /> ❑COMMERCIAL �I NDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> L-cw c� 2 00,. a IAL ❑OTHER ❑ FARM OTHER <br /> LLOCALAGENCY AGENCY CONTACTPERSON PHONE <br /> Z �^ S .:�r Loc.c-1 e., St'. Lc.v✓� i- �o'�-v1lo. (2KgLF-3Qz� <br /> W,y{ REGIONAL BARD <br /> a Y PIgNE <br /> NAME QUANTITY LOST(OILLLONS) <br /> ? L e a rzUNKNOWN <br /> rig (a <br /> ❑ UNKNOWN <br /> b DATE DISCOVERED e, HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> MI '+ OD 0 Sv (oyl ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w .1 M o .1 YJ I UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK V1 CLOSE TANK <br /> 4 HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPM ❑ CHANGE PROCEDURE <br /> o VES ❑ NO IF YES,DATE d M �-M o p 3 u S%L Y ❑ OTHER <br /> u� SOURCE OF DISCHARGETANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN ( Iou o ❑ ❑ OVERFILL RUPTURFhALURE <br /> F-1 ^ GAL FIBERGLASSE::]PIPING LEAK AGE I T YRS ❑ STEEL ❑ CORROSION N2' UNKNOWN <br /> ❑ OTHER UNKNOWN OTHER .Mow"1 ❑ SPILL ❑ OTHER <br /> �w�j CHECK ONE ONLY <br /> A� ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Fg CHECKONEONLY <br /> �6 ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Utl1 ❑ NOACTKNITAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Z ❑ CAP SITE(CO) ❑ EXCAVATE!DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> m ❑ CONTAINMENTBARRIER(CB) ❑ EXCAVATE A TREAT(ET) ❑ PUMPA TREAT GROUN]WATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HI ❑ NO ACTION REOUIRED INA) ❑ OTHER(OT) <br /> S-A co � > ;ti�� oti ✓ . Y�d d :,meq �a�.k veeo��� . 1 P %Ty, vw-j <br /> w J K J <br />