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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCAL AGENCY USE ONLY P <br /> ❑ YES NO REPORT BEEN FILED? DYES [?-'NO HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASES THE HEALTH AND SAFTY CODE. <br /> OM p M O ,J o vX v SIGNED DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> > Zc0l) YC�-3Y616� <br /> P REPRESS ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME / �y <br /> pLOCAL AGENCY ❑ OTHER ^ � h ICc 4411A Se--( t,(.- . <br /> ADDRESS <br /> C4 <br /> STREET CRY STATE ZIP <br /> NAME ti CONTACTPERSON <br /> / /PgHO�N�EA <br /> iQ L. �¢Iv>-'fRJJ ❑ UNKNOWN 3'QIYt� <br /> S a ADDRESS <br /> `0(� SPGph��s�� <br /> CRY 8 ATEp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONEp <br /> O 4 zco <br /> ADDRESS <br /> J <br /> 91S--.'6 6 <br /> �il STREET CRYO, P <br /> m CROSSSTREET �J TYPE OF AREA COMMERCIAL ❑INDUSTRIAL [D RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> �{y {yam �y ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> N <br /> 0- <br /> (700 <br /> J REGIONAL BOARD <br /> � PHONE <br /> w (11 NAME QUANTITY LOST(GALLONS) <br /> X T IGS4, 1p-oulwNOWN <br /> Y� beize-^e_ <br /> NKNOWN <br /> �- DATE DISCOVERED HOWDISCOVERED <br /> w [I--] IN ZRYCONTROL ❑ SUBSURFACE MONITORING E::] NUISANCE CONDITIONS <br /> W <br /> o.1 M Q.IeDl 9'11/ v E] TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METH OD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> w <br /> ml M .1 01 Yj YJ L'J-�/UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED 9 ❑ REPAIRTANK ❑ REPAIRPF+ING ❑ CHANGE PROCEDURE <br /> 'p ❑ YES ❑ NO IFYES,DATE ❑ OTHER <br /> M M 0 D Y Y <br /> y SOURCE OF DISCHARGE TANKS ONLY)CAPACITY MATERIAL <br /> CAUSE(S) <br /> GAL. ❑ FIBERGLASS <br /> F-] TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREFAILURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ E:] OTHER <br /> SPILL <br /> W CHECK ONE ONLY <br /> U� ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> w <br /> xa ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> UN ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) EXCAVATE&DISPOSE E <br /> S� ❑ ( D) ❑ REMOVE FREE PROOUCT(FP) ❑ ENHANCED BIO DEGRADATION(I0 <br /> ❑ CONTAINMENT BARRIER(03) ❑ EXCAVATE&TREAT(ET) PUMP B TREAT GROUNDWATER G REPLACE SUPPLY RS <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> Fu, f/te /Sl ctsSPss .cam wtL/ -4e vLecer/s� '/U s24- ca <br /> �'�'� EP' Comarni��� 4S lTP4iso!/ bc�. {�y lUGa0��41�-� a�'es�-Gyi <br /> Kscosumn <br />