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I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? ❑ THEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> YES ❑ `:REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25100.7 OF <br /> YES NO THE HEALTH AND SARY CODE. / �.�.� <br /> REPORT DATE <br /> CASES T_1/�L,-- J'-i{Yy '--DATE <br /> 1JflNED -- <br /> M M Y Y PHONE SIGNATURE /� <br /> NAME <br /> OONF11NADIVIDUAL FILING REPOR�T��)(, ' '^ 7 //. ,• . <br /> - -- COMPANY OR AGE/N+CYY NAME //��JJCC44L�••GG�� <br /> 0 REPRESENTING ❑ OWNEIVOPERATOR ❑ REGIONAL BOARD ,l <br /> s,J, �I t�iG ealf� SCrJLCe J. fn l <br /> a LOCAL AGENCY ❑ OTHER <br /> 8 <br /> a ADDRESS <br /> •O "PSO s, <br /> �/y�,L�� 5�'dc.k ►� cpY (��J sr�Te Iv <br /> `� O ' � CONTACT PERSON PHONE <br /> NAME �^ ­RD N �.m ayfe r t9i619�9-071 <br /> Q. W IZ RG-+iOA.� ❑ UNKNOWNy <br /> ADDRESS <br /> /Sfe IO srA1E aP <br /> RE tle. Cm PHDPE <br /> OPERATOR <br /> FACLITV NAME(IF APPLICABLE) 4n�'w 04/6A C ,'1�Q� '1�^l <br /> O _ <br /> ADDRESS <br /> /04 <br /> Sf W. erRiE - �e cu- YCj&Ta u)h DOUK Y <br /> r COMMERCIAL❑NDUSTRIAL❑RURAL TYPE OF BUSINESS ❑/RETAIL FUELSTATION <br /> y CROSS STREET TYPE OF AREA ❑COMMERCIAL <br /> FARM OTHERLpN�eNle✓N� eA <br /> ❑RESIDENTIAL ❑OTHER ❑ <br /> CONTACTPERSON PHONE <br /> LOCAL-AGENCY 1,�AGENCY NAME <br /> era-* <br /> � 1 '�,1 <br /> w)y PHONE <br /> REGIONAL BOARD <br /> d ( I <br /> NAME <br /> QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> wp <br /> (� ❑ <br /> Y UNKNOYM <br /> r DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i ^� TANKTEST E] TANK REMOVAL E] OTHER <br /> GAT <br /> �u E J M D Y V <br /> E DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLh <br /> ® UNKNOWN F-1REMOVECONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> w HAS DISCHARGE BEEN STOPPED T Y ❑ REPAIR TANK I� ❑ REPAIRPIPNG ❑ CHANGE PROCEDURE <br /> ❑ YES ❑ NO IF VES,DATE M M D D Y Y ® OTHER tkAYY%OWrJ <br /> SOL, OF DISCHARGE TANKS ONLV/CMACITY MATERIAL CANSELS) <br /> ❑ TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORflOSK)N ® UNKNOWN <br /> ❑ OTHER ® UNKNOWN ❑ OTHER ❑ SPILL [:] OTHER (� <br /> w� CHECK ONE ONLY 1 <br /> K536 <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKNGWATER (CHECK ONLY IF WATER WELLS HAVEACTUALLYBEEN AFFECTED) <br /> HECKONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP INPROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> � NOACTION TAKEN ❑ POST CLEANUP MONITORNG IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br /> HECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> CAPSITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT PUMPA TREAT GROUNDWATER(GT REPLACESUPPLV(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE E TREAT(ET) ❑ I ❑ <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ® OTHER(OTT) g.PJ IAV QL7, <br /> cJ..hl Wim. <br /> o a eo o dh Ub .L. Q ?ktMt w �5eo-"ecgs <br /> 4hdv c4, -c:19 a . <br /> � <br /> d X4�i�. c ovi t.���c aL o 'U 6 y - <br /> R9DKµt) <br />