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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />F-1 YES REPORT BEEN FILED 7 ]YES ❑ NO <br />I HEREBY CERTIFY THAT I AM_ GOVERNMENTLTOO YEE AND THAT I <br />SLOCAL <br />OFFIC14S PURSUANTTED <br />.REPORTED THIS NFORMA IONATO SECTION 251BD7AVE OF <br />THE HEALTH AND SAFTYTDF !� J... <br />REPORT DATE CASEa <br />pyo <br />0m 0 <br />SIGNED DATE <br />M 0 !+v r <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONESIGNATURE <br />3 <br />W ; Rv&L <br />(2o 7 P <br />REPRESENTING ❑ OWNER/OPERATOR REGIONALBOARD COMPANY ORAGENCY NAME <br />'"�^�1 <br />'/ /, {( ^., -,I <br />X LOCAL AGENCY ❑n OTHER 6 I mtrd vm TOA, <br />LG 7J r (J CUN�Iry <br />ADDRESS <br />T/�//'Sj <fA <br />64- L D,06 <br />f �4 BtATE <br />NAME /,.,,/ <br />CONTACT PERSON PHONE <br />Ale Z,6�g td 5 A M UNKNOWN <br />r ( 3s�J f <br />uADDRESS <br />511-loo 7ye,*c-Ca 9S^3P7,(!5 <br />�A <br />FACILITY NAME (F APPLICABLE) <br />/✓e x,5.9/e! <br />OPERATOR PHONE <br />( ) <br />w .Tee -�cGcad/ <br />i <br />ADDRESS ? 9'S <br />22/ 00 ./Tko57Lw 4 cm c IVY <br />qCROSS <br />STREET <br />TYPE OF AREA ❑ COMMERCIAL 0 INDUSTRIAL ❑ RURAL <br />TYPEOFBUSINESS ❑ RETAILFUELSTATION <br />0 RESIDENTIAL ❑ OTHER <br />❑ FARM L:j OTHER <br />LOCALAGENCY AGENCY NAME coUCONTACT <br />PERSON <br />PHONE <br />m <br />w96 <br />' .T mow; <br />(V d=3(/zo <br />Iy � <br />REGIONAL BOARD <br />(HONE�� ��b <br />) <br />(1) NAME OU TRV LOST (GALLONS) <br />/i ne, <br />a5Q UNKNOWN <br />�- <br />❑ UNKNOWN <br />i <br />DATEDISCOVEREDA <br />`/�� <br />HOWDIBCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCEGONDITKINS <br />M ✓o /o W Y <br />❑ TANKTEST ® TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />ml mi 01 01 Yl Y 0 UNKNOWN <br />❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSETANK <br />w <br />❑ REPAIR PIPING E]CHANGE PROCEDURE <br />GEBEEN TOPPED <br />HAS DISCHARGE <br />❑NO DATE M M D D YJ y <br />❑ <br />E]OTHER <br />yLI <br />3 <br />SOURCE OF DISCHARGE <br />TANKS ONLYCAPACITY MATERIAL <br />CAUSES) <br />❑ TANKLEAK N UNKNOWN <br />VOO GAL. <br />❑ OVERFILL O RUPTUREFAILURE <br />❑ PIPING LEAK <br />�/❑,/FIBERGLASS <br />AGE /y� _ YRS /? STEEL <br />L] CORROSION [�2UNKNOWN <br />O OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />CHECK ONE ONLY <br />ywW <br />❑ UNDETERMINED ❑ S01LONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />X SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />8 m <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />S zO <br />CAP SITE (CD) ❑ EXCAVATE A DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) 0 ENHANCED BK) DEGRADATION (IT) <br />0 CONTAINMENT BARRIER (CB) ❑ EXCAVATE TREAT (ET) ❑ UMPB TREAT GROU`N,D^WATER (/GT�)/J❑ REPLACE SUPPLY IRS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTON REQUIRED INA) F OTHER (OT) <br />ergrvN, rate n V5 re- 6ft 0V CCo <br />+Ole avv GN!// 6e- i �q u �;e v a � , dGfe a of i ., e- <br />"a 5 <br />71e h aYu/"G a� e X�� f of eo.L�7AX4 A.�iv� <br />u�e{� 6 � p�-oPre I%f u/a niz�. <br />V1 -u3 K8CA61w <br />LOU <br />