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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? YES 0 NO 1 HEREBY CERTIFY THAT i AM A 0ESK.PkEb GIDYERNMENT EMPLOYEE AND THAT t HAVE <br /> [] <br /> YES NO REPORTED THIS INFORMATION TO LOCAL OFF[CIAL S PURSUANT TO SECTION 25180.7 OF <br /> REPORT^yD�ATE �/(nJ CASE* X;q�; <br /> M 6 Y.A D D / Y S� /7A <br /> TE - <br /> NAME OF INDIVIDUAL FILIN PORT PHONE SIGNATU E <br /> bb 6e <br /> o REPRES ING OWNER/OPERATOR REGIONALBOARD COMPANY ORAGENC NAME <br /> cr LOCAL AGENCY OTHER 'l�(� o I u /e <br /> w //�� 7 <br /> a0 ADDRESS 7�OS DI <br /> o a oo DRY• STATE ZIP <br /> �NAME <br /> CONTACTPERgSON PHONE <br /> Vr4v UNKNOWN <br /> �Db <br /> cr <br /> //nff <br /> a ADDRESS �`l� C�I 61 Y5 C3 <br /> w `�+ J Q <br /> ¢ �„J�o I FOS 1 �/r STREET W CRV STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> zi Br ( ) <br /> Q <br /> � ADDRESSq <br /> 74 7162cis-�r`c- /4lfe, cY�i4 <br /> I/ ZIP <br /> yCROSS STREET '^n A TYPE OF AREA OMMERCIAL O INDUSTRIAL �RURAL TYPE OF BUSINESS � RETAIL FUEL STATION <br /> hla44 -y RESIDENTIAL [:]OTHER a FARM OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> wW u S- �� D,` ,btu (�oi)Y6f-3 as <br /> � <br /> w w REGIONAL BOARD LqPHONE <br /> CL <br /> (t) NAME ,QUANTITY LOST(GALLONS) <br /> Q ✓�/�( �C/� �� Y t�/WV,�/ KNOWN <br /> 0 <br /> I-0 (�) <br /> cn UNKNOWN <br /> z DATE DISCOVERED J((� HOW DISCOVERED O INVENTORY CONTROL a SU URFAC MONITORING O NUISANCE CONDITIONS <br /> _7` D V v �Y 0 TANK TEST TANK REMOVAL OTHER J <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN F7 REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> cc IIw M M D D Y Y <br /> HAS DISC GE BEEN STOPPED? REPAIR TANK REPAIR PIPING a CHANGE PROCEDURE <br /> YES NO IF YES,DATE OMJ MI l!) III ODI '?Y9Y OTHE R <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK UNKNOWN Qj 0,0 0 GAL. O FIBERGLASS 0 OVERFILL a RUPTURE/FAILURE <br /> cc 0 PIPING LEAK AGE YRS STEEL a CORROSIONKNOWN <br /> OTHER NKNOWN OTHER SPILL a OTHER <br /> W w CHECK ONE ONLY <br /> 0 UNDETERMINED SOIL ONLY O GROUNDWATER a DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> w <br /> cc <br /> < O SI INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U y NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS E:] NO FUNDS AVAILABLE TO PROCEED = EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4Z F-] CAP SITE(CD) O EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> 00 <br /> E] CONTAINMENT BARRIER(CB) a EXCAVATE&TREAT(ET) n P&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT ATHOOKUP(HU) NO ACTIONREQUIRED(NA) � op <br /> THER(OT) <br /> ct <br /> Of IN,%— <br /> m0 8 r' e a - F Vii` 4?s�� ��e l <br /> v7s rl�mr er-x/��r <br /> - 1,j 14 .1 JAa/�u� <br />