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9 • <br /> 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? HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES ld NO ❑YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OF [ALS PURSUANT TO SECTION 251801 OF <br /> REPORT DATE J CASES THE HEALTH AND SAFiY CODE y Jljy/ ;�'�'�i <br /> 2 meq/ S � : <br /> M M / D Y Y SIGNED DAT <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> SVAvE` (w ' <br /> 0 REPRESENTING ❑ OWNEWOPERATOR ❑ GIONAL BOARD COMPANY OR AGENCY^NAME <br /> ¢o ® LOCALAGENCY ❑ OTHER S /�{ TAC IN L-wC?T� I*AL <br /> 0 <br /> ADDRESS <br /> A01 E 461PA?4utV'^ CITYS STATE 64 9 <br /> ZIP OI <br /> NAMEp c DOA <br /> PHONE �/�(� <br /> USSTT llj� UNKNOWN Q 30`3 1* <br /> i ADDRESS C�p��� / // <br /> I gRaaW cm J r1a.�C.+T����PJr / ATE`- ` �✓ 0 L <br /> FACILITY NAME(IF APPLICABLE) OPERATOfl PHONE <br /> 9 C SA S 7F ��u� ,(` c <br /> ADDRESS7, <br /> ! V - cRY S• �/ a�=�. Si �/ <br /> / TYP FBUSINESS <br /> -q CROSS STREET TYPEOF AREA ❑COMMERCIAL INDUSTRIAL ❑RURAL ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER <br /> LOCALAGENCY _ AGENCY NAME {�IJI CONTACT PERSON PHONE <br /> s N ✓d ��N 3 <br /> REGIONAL BOARD PHONE <br /> CV �✓ C B ( ) <br /> NAME OUANTRY LOST(GALLONS) <br /> (') —fb7gL_ OIL, ANd GKf�RS UNKNOWN <br /> 0 (2) -- ^ _/ <br /> 1 Tann �'jgOtOuM D1ZJcAR$O/Yf UNKNOWN <br /> O <br /> DATE DISC! VVER�EDDSVHOW DISCOVERED ❑ INVENTORY CONTROL [:] MONITORINGSUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> wit M51 o .1 v�v ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CLOSETANK <br /> y M M 0 D Y I V <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPING ❑ CHANGEPROCEDURE <br /> p '541 YES ❑ NO IFYES.DATE M M o D Y Y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK " UNKNOWN '5BGAL. .❑/FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPINGLEAK AGE YRS 7STEEL ❑ CORROSION X UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> CHECKONEONLY <br /> l3 UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> 2< ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �N ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAMBLETO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 0 <br /> 2 F--] CONTAINMENT BARRIER IDS) ❑ EXCAVATE&TREAT(En ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RB) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED INA) OTHER(OT) <br /> So iL Gonr?�n�in/.47io� o Sir- �}ssess.,.c. t �iv, <br /> w <br /> HWM(4� <br />