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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />YES REPORT BEEN FILED? O YES ❑ NO <br />ADESIGNATED GOVERNMENT EMPLOYEE HAVE <br />INFORMATION <br />REPORTED THISTO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />THE HEALTH AND SAFfY CODE <br />REPORT DATE CASE# <br />c <br />0.161104 <br />`�p ` yl Y <br />SUNLOpp <br />NAME OF INDIVIDUAL FILING RT <br />PHONE SIGNA <br />REPRESE G 0 OWNER)OPERATOR 0 REGIONALSOARD <br />COMPANY OR AGENC,YY� NAME <br />LOCAL AGENCY 0 OTHER <br />ADDRESS <br />�o. TeX moo ch C 9 <br />Cm STATE 2P <br />12 <br />y <br />NAME <br />(,D �UNKNOWN <br />CONTACTPERSON PHONE <br />ADDRESS o <br />�Sfocf'6� C/� q�?o/ <br />BTREEf CRY SPATE P <br />FACILITY NAME IF APPLICABLE) <br />ca/ ��f <br />OPERATOR PHONE <br />- <br />�> <br />e <br />5y� <br />ADDRESS <br />, 4-�Cim�f f <br />P/ C19 175'dIW6 <br />f- , <br />O �'S MEE-� <br />CWNTY ap <br />yCROSSSTREET <br />TYPE OF AREA O COMMERCIAL INDUSTRIAL O RURAL <br />TYPEOFBUSINESS O RETAIL FUELSTATION <br />.L3Pcik.-� 0-/I1� <br />Q RESIDENTIAL 0 OTHER <br />Q FARM O OTHER <br />LOCALAGENCV AGENCYNAME <br />CONTACTPERSON <br />PHONE <br />€ <br />S PHS - F4. 61, <br />v� uji soy,-) <br />(,A0F)YAF,3ylo <br />w;N <br />REGIONAL BOARD <br />PHONE <br />(1) NAME QUANTITY LOST (GALLONS) <br />pey J cO UNKNOWN <br />J <br />~ Q <br />M <br />\v <br />❑ UNKNOWN <br />�MD`SCMVEREO 90 �Y ^v <br />n ,SUBSURFACE EMONRORWG O NUISANCE CONDITIONS <br />VERED �TIANK <br />�O CNK <br />i <br />✓ p-Tt U <br />REMOVALVENTORYCO <br />TEST LrJ�/ <br />DATE DISCHARGE BEGAN <br />METH�O TO STOP DISCHARGE (CHECK ALL THA APPLY) <br />w <br />M M o o v Y Ep UNKNOWN <br />REMOVECONTENTS REPLACE TANK CLOSE <br />> <br />� REPAIR TANK E] REPAIRPIPING E] CHANGE PROCEDURE <br />HASDISC RGEBEENSTOPPED7 ,�{{ �yy <br />3o ? <br />5 <br />VES O NO IF VES, DATE /M / M U <br />C.J DI v <br />0 OTHER <br />u� <br />SOURCE OF DISCHARGE <br />TANKS ONLYACAPACITY MATERIAL <br />CAUSES) <br />O TANK LEAK UNKNOWN <br />6 OO O CAL. Q FIB E GLASS <br />Q OVERFILL Q RUPTURE/FAILURE <br />PIPING LEAK <br />AGE YRS STEEL <br />CORROSION UNKNOWN <br />F7 OTHER <br />UNKNOWN Q OTHER <br />O SPILL 0 OTHER <br />wT <br />CHECKONEONLY <br />UNDETERMINED SOIL ONLY 0 GROUNDWATER D DRINKING WATER(CHECK ONLY FWATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECK ONS ONLY <br />W¢� <br />❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS O SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />Uy <br />OACTION TAKEN Q POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION($) (SEE BACK FOR DETAILS) <br />oCAP <br />SITE (CD) EXCAVATE A DISPOSE (ED) REMOVE FREE PRODUCT (FP) ENHANCED BIODEGRADATION (m <br />❑ CONTAINMENT BARRIER (CB) O EXCAVATES TREAT (ET) PUMPS TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />TREATMENT AT�HOOKUP (HUU))�� ENNO ACTIONREQUIREDINA) <br />w <br />,(O/T) <br />��OTHER <br />/�� ' �L �YL� <br />�/!%� <br />f <br />�s�l'"G w c^�V7 W 7 ✓V u/Il r .-y vG�(/[�G� <br />NSC M(W) <br />ti <br />