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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY ' <br /> D THAT I HAVE <br /> YES �� REPORT BEEN FILED 7 1 HEREBY CERTIFY THAT I AM A DESIGNATED El YES Q ND REPORTED THIS INFORMATION TO LOCAL OFFGICIALVURSUANT NT OO SECTION 25180 aF. <br /> REPORT��DYYATE CASES THE HEALTH AND SAFTY <br /> OM OMI V UY v <br /> SIGNEDI SIGNEDDATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI TU . <br /> 0 REPRE�G OWNER'OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY O OTHER �- <br /> aADDRESS �•� /��//..//- G�•ld/ <br /> ?C) STREET CrtV LJ STATE V/ 1 iZIP <br /> NAME M �.A CONTACTPERSON PHONE <br /> rAWZp <br /> �W v �9/ d S//•i/�(/�v� G. �i - p <br /> 13-211(UNKNOWN <br /> ADDRESS <br /> 129 <br /> 9 <br /> 11~ / ECRY qh /7VZ.05L BATE P <br /> FACLITY NAME(IF APPLICABLE) <br /> OPERATOR PHONE <br /> Moav;rq ✓ l'oezey 460sr (Pi3-1-16t� <br /> ADDRESS <br /> TT <br /> STREET 7/VQ �� CRr ��7 N wulm ap <br /> y CROSS STREET TYPEOFAREA MMERCIAL O INDUSTRIAL 0 RURAL TYPEOFBUSINESS 0 RETAILFUELSTATION <br /> O RESIDENTIAL O OTHER O FARM [71 OTHER <br /> g LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> ;y REGIONAL BOARD PHONE <br /> =YY CEv L v e ( ) <br /> (�) NAME QUANT17Y LOST(GALLONS) <br /> (2) <br /> �j UNKNOWN <br /> r DATEDISCOVERED HDWDISCO D O INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCECONDITIONS <br /> V u �7 u V D / D Or ✓ r TANK TEST Q TANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D v Y UNKNOWN REMOVECONTENTS O REPLACE TANK CLOSE TANK <br /> HAS DI RGE BEEN STOPPED 7 � REPAIR TANK O REPAIR PIPING CHANGE PROCEDURE <br /> p YES O NO IFYES,DATE uI M o ID v v O OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYCCAPACITY MATERIAL CAUSE(S) <br /> 4 O TANKLEAK a UNKNOWN GAL. Q FIBER 3 O OVERFILL RUPTUREFALURE <br /> I[J PIPI LEAK AGE r� YRS TEEL CORROSION O UNKNOWN <br /> OTHER UNKNOWN Q OTHER O SPILL O OTHER <br /> CHECKON NLY <br /> UNDETERMINED O SOILONLY O GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> cZ O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) = CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �y 0 NOAGTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEEDEVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 O CAP SITE(CD) O EXCAVATE A DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> O CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(EI) O PUMP REATGROUNDWATER(GTTT)) REPLACE SUPPLY IRS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED INA) OTHER(OT) �!!$ h, <br /> 6Zv 5�®�& �uAST�o�L T /� r��n STs �2Eois�on/ iesT. errs s�Pr— <br /> fsxT GULL �3E �El�ui/G�� d OL-ic�lHiiU� �-G,Z/T o��!/ls/z//•tfq%/oY <br /> 2C r/erw� dY rs� �9P, Pir�.�T�®Qdly�el. xy <br /> HaC�IAa/1 <br />