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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY.USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATEQ GOVERNMENT EMPLOYEE AND.THAT f:HAVE ❑ AS Y NO ❑YES E:] NO REPORTER THIS INFORMATION TO LOCAL OFFICIALS:PURSUANT TO SECTION 25180.7 OF REPORT DATE CASE 0 T �HEALTH AND SAFTY CODE _ rr// �^ YfJ�d4 �CLG✓CU4 �!c�✓." � t :) ��" (�� i' i M (M 2 SD 6 Y Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU m �av�Q �e rIS (Zoq) LIC,F-3 Y4-0 1 ---- REPRESENTING ❑ OWNER/OPERA-OR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME 1 y 1l ¢ LOCAL AGENCY ❑ OTHER 'ja - ��4 •�� L..,l O a ^ Q ADDRESS,' \ I c-A '5? t STREET CITY STATE ZIP NAME \ ` CONTACT PERSON PHONE Cc't�o ►J�� ❑ UNKNOWN vo C"- dZ Er Qa ADDRESS . �� ` C w r 1 Q �JS2 ��S E YoI ter A�� oc �.. STREET CRY STATE 21P FACILITY NAME(IF APPLICABLE) OPERATOR PHONE ADDRESS 1 2STREET g- / S -`S-� STRSTR J o� W (,.., EET � CRV OUN P Y- CROSS STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL ❑RURAL n'PE OF BUSINESS ❑ RETAIL FUEL STATION N ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE ( 01) 46(f w Lu w REGIO AL BOARD PHONE IL (�) vu NAME QUANTITY LOST(GALLONS) Z� UNKNOWN Lu Q J 1 ~O (2) UNKNOWN z DATE DISCOVERED HOW DISCOVERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS M ZM �o JD V Y ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK �CLOSETANK M M D D V Y HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK El REPAIR PIPING CHANGE PROCEDURE o YES ❑ NO IF YES,DATE (M � p Up a Y �Y ❑ OTHER w I SOURCE OF DISCHARG TANKS ON�►L^Y-/CCAAP�ACITY MATERIAL CAUSE(S) ❑ TANK LEAK UNKNOWN J`� GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE ElPIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL E:] OTHER w w CHECKONEONLY 0 ❑ UNDETERMINED FVT SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER. (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) w 12 ccc y NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) w PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) w� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ ¢ ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) c� Z Lu 8 HSC 0514/87)