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d <br /> i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCALAUNCY USE QNLI( <br /> YES �NO REPO R7BEEN FLED? ❑YES dN0 I;EER£BY GERT(FY;TE+A A 0 $isNAT�R GQV (f ...... EMPGI)YEE-JWQ FHAT:�k(AVF <br /> REPORTED:THIS.NiF RMn.] t iGAl t?FF(Crta s PURsuAhff TQ SECTION 25t8d 7+7F <br /> REPORT DATE CASEi1 THE V AND SAF7Y <br /> N <br /> 0-1 q M Q o v ANTE <br /> NAM OF INDIVID L FILING REPORT PHONE SIGNA RE <br /> V-3- <br /> 0 <br /> 0 REPRESENTI COMPANY OR AGENCY NAME <br /> ❑ OWNERIOPERATOR ❑ REGIONAL BOARD <br /> O ©OCAL AGENCY [:] OTHER <br /> R <br /> ¢ ADDRESSSTREET <br /> CITY STATE ZIP <br /> NAME CONTACTPERSON PHONE} � <br /> 1 t'L- 5a� ❑ UNKNOWN �%C L /{�^) 1731—.41,9101 <br /> aADDRESS - c/!l , ,Lu <br /> C.�rry STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATORHONE <br /> z 1)LL CCEpW �i zL � 7,201 <br /> r73/—v9Ca 1 <br /> ADDRESS <br /> CITY ap <br /> y CROSS STREET STpeEr TYPE OF AREANIERCIAL❑INDUSTRIAL RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> RESIDENTIAL ❑OTHER FARM E fR <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> LREE}GIIO�NfAL�BOARD PHONE <br /> (,y NAME GUANTITY LOST(GALLONS) <br /> 0I ®-UNKNOWN <br /> (2) <br /> L./lo LEw�"'F1 L-r ez_ F, KNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> V M / M Do -�Lol ?,I ❑ TANK TEST �NK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> gNKNOWN �MOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> W M M O D V Y <br /> HAS DISC ES G�ESTOPPED YES,DATE � M � o Oo �r v �D7HEIR 7A����❑ REPAIR PIPIN6 ❑ CHANGE PROCEDURE <br /> O E:] /k- <br /> u�l SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK �ZrUNKNOWN 7JV, GAL. ❑ FIBERGLASS E::] OVERFILL Ej RUPTUREIFAILURE <br /> ¢ ❑ PIPING LEAK AGE YRS N?-STEEL ❑ CORROSION ®UNKNOWN <br /> F-1OTHER ©UNKNOWN ❑ OTHER ❑ SPILL O OTHER <br /> Lu CHECK DN NLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER Q DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> Qa ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> r <br /> co <br /> ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> W ❑ CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTIDN REQUIRED(NA) ❑ OTHER(OT) <br /> �l,�.r fft�.� 5>r-f.� c�5s-�srs-�er�f' cvj 11 bI� ►�`��`u.r rid "� ��e rvrL�-� -z�/i� .���c.c.hG <br /> HSCOS(4W) <br />