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C/- _? /--J L1.2 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR FOR LOCAL AGENCY USE ONLY <br /> O YES NO REPORT BEEN FLED? 0 YES No REPORTED THIS NFORMATIIHEREBY CERTIFY THAT I M A DESIGNATED GOVERNMENT <br /> PURSUANT EMPLOYEE <br /> SECTION 251807AOF <br /> REPORTDATE CASE# IJ �^' THE H TH AND SAFTY COD . <br /> 9M 70 3Y NESpgTE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> o REPRESENDT O <br /> OWNER/OPERATOR O REGIONAL BOARD COMPANYORAGENCV NAME <br /> p LOCAL AGENCY O OTHER c _ t4S-F- <br /> k`v <br /> ALl DDRESS N's N' V /l STATE J"SZpo� <br /> �8 EET ��- CffY <br /> NAME `N CONTACT PERSON \ PHONE <br /> e U 1. 11, . ❑ UNKNOWN O e- V �0 v1�1 (ZD') .SSfS <br /> <y <br /> ADDRESS <br /> LJ <br /> ,/,/T / G y��� 1_ /� 7 J <br /> `�O I w, L a�II STHEl N O J.l O V p CT' S-\l LC-CU n STATE EA Cv p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> L-j c) pol e <br /> ADDRESS 6c <br /> � Z b srneErL0.•'L cmS ck- couKTY�L ! 'zOf3 <br /> y CROSS STREET TYPE OF AREA OOMMERCWL O WDUSTRIAL O RURAL TYPEOFBUSINESS RETAIL FUEL STATION <br /> \� O RESIDENTIAL 0 OTHER O FARM OTHER <br /> LOCALAGE CY AGENCY NAME CONTACTPERSON PHONE <br /> w l (o . f N-s ?p <br /> (2 yb k EW <br /> w REGIONAL BOARD <br /> u PHONE <br /> cz <br /> w (11 NAME OUANTRY LOST(GALLONS) <br /> So I ; ✓( UNKNOWN <br /> (2) <br /> N <br /> C- LUNKNONM <br /> i OATE DISCOVERE1D HOW DISCOVERED O INVENTORYCONTROL O SUBSURFACEMONITORWG ) O NUISANCE CONDITIONS <br /> In, N b I o �v O TANK TEST O TAWREMOVAL R ' l� jq,Rj <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> w M1 M .11 YJ YJ Rr�UNKNOWN ❑ REMOVECONTENTS O REPLACE TANKCLOSE TANK <br /> HAS DISCHAR EEN STOPPED? O REPAIRTANK O REPAIRPPWG O CHANGEPROCEDURE <br /> p YES O NO IFYES,DATE 'j�jo Y r D OTHER C� <br /> u� SOURCE OF DISCHARGE TANKS ONLY.CMAPACITY MATERIAL CAUSE(S) ) <br /> TAN7GAL. OVERFILL O RUPTUREIFALUREOUNKNOWN LOFGb <br /> UQ PIPING LEAK AGE YRS E;�EL O CORROSION UNKNOWN <br /> O OTHER UNKNOWN O OTHER O SPILL O OTHER <br /> ywy CHECK ONE O Y <br /> c3� UNDETERMINED O SOILONLY O GROUNDWATER O DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUAL LYBEENAFFECTED) <br /> F CHECKONEONLY <br /> 2 H <br /> S< O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> O NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> �Z O CAP SITE(CD) O EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) O ENHANCEDBIODEGRADATION(IT) <br /> aO CONTAINMENT BARRIER(CB) O EXCAVATES.TREAT(EID O PUMP&TREAT GROUNDWATER[GT) O REPLACE SUPPLY IRS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED INA) O OTHER(OT) f <br /> .y- `v iT"�+t/ lA✓GS� T/`o7 E✓#T// <br /> i �L eX 7'C� � JLjL' CG/JYS�)✓!G T/m n <br /> Ae- <br /> 8 <br /> HSC M(4S7) <br />