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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGE C $E LY <br /> REPORT BEEN FILED? <br /> ❑ YES 0'� [::]YES ❑ NO I HEREBY CERTI T AII M'A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED TH7 IN ATION TO L CAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORT GATE CASEi THE HEALTH 91ns DE j <br /> 1 Ic"l t 8 <br /> �R SM 1 S D S v d v SIGNED GATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE / <br /> yav V ✓(S (2rz) ) 4b�- 3 qqp <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> w¢ �4CAL AGENCY ❑ OTHER <br /> Spun Joq L �e- 14,, <br /> ¢ ADDRESS `\ (� , <br /> 1601 Fi el-}oln rr p.o. QoK 2ooh \�M C-A <br /> CITY <br /> AME n CONTACT PERSON &FATE ip <br /> ZQ �( � { r✓O�Qi C✓-S ❑ UNKNOWN Dew„�,Y$ fq q� PHONE <br /> g (209) 33y - 3362 <br /> y ADDRESS ^ <br /> ¢ 1601 C iNTC CB�BEEr L✓r' �^wCT'� G(er0 c-A g Sos'4� <br /> LRY <br /> FACILITY NAME p <br /> NAME(IF APPLICABLE) OPERATOR PHONE <br /> $ PAcifTT� Cost Pvod-,e,✓s -LdX, (20433`/ - 33S'2- <br /> ADDRESS <br /> 3 Z E Tek- S t 9 BEE L �8 I Gja n�oq 9 52c�o <br /> y CROSS STREET TYPE OF AREA crtzp <br /> "REET P-CdMMMERCIAL ❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUELSTATION <br /> is, ❑RESIDENTIAL ❑OTHER ❑ FARM -OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w N ke<tAL. D-ts4,rICI �iAl (Z CI) 'fE--,f"S Y2 - <br /> itw REGIONAL BOARD VPHONE <br /> a <br /> C ems!✓.I V qll <br /> 36 r-S-6o0 <br /> w (1) u NAME QUANTITY LOST(GALLONS) <br /> ❑ \ I1 <br /> [t]-uNKNowN <br /> ❑ UNKNOWN <br /> W DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> MM 3 M 'D �Y �v ❑ TANKTEST ❑L-7ARK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METH OD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w Ml MI 01 DI Yl y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK �TANK <br /> Q HAS DISCHARGE BEEN STOPPED 7 D REPAIRTANK E] REPAIRPIPING CHANGE PROCEDURE <br /> B ECJ ❑ NO IFYES,OATE pM NMI 7--.1r-D v 7--y ❑ OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLWCAPACITV MATERIAL CAUSES) <br /> ❑ ❑ TANK LEAK UNKNOWN GAL, ❑ FIBERGLASS <br /> ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION �KNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER O SPILL ❑ OTHER <br /> ww CHECK ONE ONLY <br /> as <br /> OF ❑ UNDETERMINED LnSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F- CHECKONEONLY <br /> ¢< ❑ <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> w4 ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E:] ENHANCED BIO DEGRADATION(IT) <br /> w ❑ CONTAINMENT 13ARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> a <br />