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} <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY:7NO <br /> FOR LOCAL AGENCY USE ONLY <br /> El YES �NO REPORT BEEN FILED 7 ❑ YES I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT(HAVE. <br /> REPORTED THIS WFt)RMATION TO WCAL CFF. ., S P� SUANT TO.SECTION 25184 7 OF: <br /> REPORT DATE CASE s THE HEALTH AND WTV DE, <br /> '" o �v D r SIGNED, DAT <br /> _. . <br /> NAME OF INDIV UAL FILING REPORT PHONE SIGNATURE <br /> LLb"M 5-NAV <br /> REPRESENTING ❑ OWNEITOPERATOR REGIONALBOARD COMPANY OR AGENCY NAME <br /> 0 X'LOCALAGENCY ❑ OTHER � <br /> GutJG �ST.�'/c <br /> ADDRESS <br /> l o' EEf-7-'o o CITY STATE -` TIp � 7 <br /> NAME , / /� CONTTAA-TPERSON J_�} / PHONE ) �{ <br /> mFn it / /l 1 I�QJ'1.� k� ❑ UNKNOWN /�L+f✓ ✓/7(C o o <br /> D 03 <br /> { _ <br /> D ADDRESS <br /> / 4/if- <br /> �e CRrr /`'`// STATE ZIP <br /> ' STREET �l /u�--•7 �C+��L'` ,-� <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> '~ A N " ( } <br /> 4 ADDRESS <br /> W3TREET + �bep- <br /> CROSS STREET f ,p TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> �i`YIJv d�Y�O# ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> SArr �u rr� tic s. 1i, tom, b r 57r�r r r-r' C �r� (2w M6 -NAC <br /> w REGIONAL BOARD PHONE <br /> 2 VR WG <br /> 0 (1) NAME QUANTITY LOST(GALLONS) <br /> w� <br /> 000. / PUNKNOWN <br /> (2) <br /> 2- <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW pISCOVEREO ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> LU ! � Z. � ( ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> Xo r v <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o r v UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 Ir ❑ REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE - o �v r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> �4� ❑ TANK LEAK ,X UNKNOWN Q p GAL, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION N? UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z0 <br /> Lu <br /> Cc <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONISI(SEE BACK FOR DETAILS) <br /> o zo <br /> F-1CAPSITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(1T) <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> KT/1F,E' S iL, A-SseSS YN�� 4.0:'[_ /,� re- (It/TLS -f-*, <br /> z cue ke'T m ,n e e ti G.+t4 re, a t d e_x*e vtf o r Ca,�7/V-M h-4A710 N <br /> I / MSC 051271 <br />