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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY f. <br /> YEE AND THAT I HAVE <br /> F-1 YES ❑ NO REPORT BEEN FILED? ❑YES O NO REPOEBY CERTIFY THAT I AM RTED THIS INFORMATION TO DESIGNATED <br /> OFFICIALSNMENT PURSUANT TO SECTION 251807 OF <br /> REPORTOATE / � CASE4 THE HEAL YCODE <br /> o O Y Y SIGNED '- DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHUN v SIGNATURE <br /> 0 REPRESENTING F-1 OWNER/OPERATOR REGIONALBOARD COMPANY OR AGENCY NAME <br /> ¢O [ ; OC AL AGENCY F7 OTHER <br /> 6 <br /> ADDRESSS� <br /> (� /� /J,//��� <br /> / C) 13v`V�STREEf CITY STATE <br /> NAME CONTACT PERSON PHONE �+ <br /> IN T UN K OWN �,. r- (OlPrl) 3 <br /> z� <br /> <y ADDRESS <br /> ¢ <br /> f4vv/ STREET GRV ITATE <br /> FACILITY E(IFAPPLICABLE) OPERATOR PHONE <br /> i ADDRESS f/� ,y/ �� �33y <br /> 7 7 STREET CRY ✓ ' 'lY�"'w�'" C P <br /> m <br /> CROSS STREETTYPEOF MMERCIAL ❑ INDUSTRIAL ❑RURAL TYPE OFBUSINESS AIL FUEL STATION <br /> O RESIDENTIAL O OTHER ❑ FARM ❑ OTHER <br /> . m LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w w REGION D PHONE /- <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> U �L/ ❑ UNKNOWN <br /> (2) <br /> - ❑ UNKNOWN <br /> DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE M NITORING ❑ NUISANCE CONDITIONS <br /> i <br /> M M /213161o1 Yl v ❑ TANK TEST ❑ TANK REMOVAL Ejj�'OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT LY) <br /> ❑ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> MM D <br /> }QQQ� HAS DI HAR EBEEN STOPPED? ❑ REPAIR TANK O REPAIR PIPING O CHANGE PROCEDURE <br /> O ES O NO IF YES,DATE M M o o v v OTHER <br /> u� SOURCE OF DISCHARGE TANKS <br /> ONNLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN 6t OE/d GAL. O FFIBERGLASSOVERFILL ❑ RUPTURFJFAILURE <br /> � <br /> O PIPINGLEAK AGE YRS �I STEEL ❑ CORROSION ❑ UNKNOWN <br /> OTHER UNKNOWN ❑ OTHER ❑ SPILL O OTHER <br /> wL CHECK ON NlY <br /> p� UNDETERMINED ❑ SOILONLY O GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> rta ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESS= SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> VN [LNO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED O EVALUATINGCLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> oO CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> i� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) A <br /> w W-e e��fd-mti <br /> RSC W(4S <br />