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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) 1 CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGEN ERVICES FOR LOCAL AGENCY USE ONLY <br /> REPOR78EEN FILED? I HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNM <br /> EMERGENCY ENT EMPLOYEE AND THAT HAVE <br /> YES NO YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25100.7 OF <br /> & � _ f _ <br /> REPORTDDDA,TE 9 CASES )' ;" <br /> DM �+ M O �Y Y DATE <br /> /�(�/ PHONE <br /> SIGNATU <br /> NAM F�DI (L F� l�P�.L" kG J `^'`--' ka(.lJ <br /> > C/ COMPANY OR AGENCY NAME A q <br /> 0 REPRESENTI ❑ OWNEWOPERATOR ❑ REGIONAL BOARD UJ p , 1 -s � <br /> ¢o OCALAGENCY ❑ OTHER 1µI ^ Q <br /> ADDRESS `O (] �� IP <br /> TE <br /> / <br /> (, / 3fATE <br /> D= <br /> STREET CONT TPERSON <br /> PHONE /y5 ' q/7L. <br /> NAME '�I !/% r <br /> IS <br /> ND r Im Q G �I' C" ❑ UNKNOWN <br /> iwADDRESS <br /> � 3TE 2P9S4�� IT a 15 //,/ AS <br /> OPE TOR PHONE y^ <br /> FACILITY AME(IF APPLICABLE) <br /> D Q Cj TVl r yam{/��� �/{-✓. 9 l <br /> ADDRESS Tw1� 1�!'�-(fi/✓`�. [/ S�" S G <br /> sTREEr crtv TYPE OF BUSINESS RETAIL FUELSTATION <br /> mCROSS STREET TYPE OF AREA MMERCIAL❑INDUSTRIAL❑RURAL /❑ <br /> !�\1�/J /, ' ^, ❑RESIDENTIAL ❑OTHER E] FARM Irl- OTHER <br /> v"" �ry CONTA PERSON PHONE <br /> ffl <br /> mi L�(OtlCALA�GENC�YI <br /> D <br /> ��� <br /> -,3 <br /> PHONE <br /> wREGIONAR //lY/'crmLOST(oALONs <br /> L y <br /> WN <br /> w <br /> UW <br /> g- (2)) ❑ UNKNOWN <br /> m HOWDISCOVERED ❑ INVENTORY CONTROL E] SUSSURFACEMONITORING ❑ NUISANCE CONDITIONSDATE DISCOVERED <br /> O �o (x�Y7 Y E] TANKTEST �/fANK REMOVAL ❑ OTHER <br /> M �M / o <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> DATE DISCHARGEBE,AN /NKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> N M ° . ° Y Y fELl4' ❑ REPAIRTANK ❑ REPAIRPIPWG ❑ CHANGEPROCEDURE <br /> i �/ <br /> / ��T( ❑ OTHER <br /> o YES ❑ NO IFYES,DATE DM M /1 R " `0 Y Y <br /> HAS DISC GE BEEN STOPPED T CAUSE(S) <br /> w SOURCE OF DISCHARGE / TANKS ONLWCAPACITY MATERIAL <br /> ❑ amu/ ❑ FIBE LASS ❑ OVERFILL ❑ RUPTURE�FAILURE <br /> TANK LEAK UNKNOWN ��-_— <br /> AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ PIPING LEAK E] OTHER <br /> UNKNOWN ❑ SPILL E] OTHER <br /> ❑ OTHER ❑ <br /> w w CHECK ON NLY <br /> UNDETERMINED ❑ SOIL ONLY F-7 GROUNDWATER F-7DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON V <br /> w� SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP INPROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> VN ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILA13LETOPROCEEO ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 1 CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) gEMO FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ ❑ <br /> S P 6TREAT GROUNDWATER(GT) ❑ EPLACE SUPPLY(RS) <br /> w� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6TREAT(ET) ❑ <br /> RED(NA) OTHER <br /> (OT) <br /> NO ACTION REW <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ ' <br /> laboru cl 4 89 r'eve <br /> 'n `�° za ani tit 2 n�z�n� <br />