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1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGATHAM <br /> Y <br /> ❑ YES 1�0 REPORT BEEN FILED? Ej YES a NO �EEREBY CERTIFY PORTED THSTO SI TED G AL OFFIALS PrU UANT 0 SECTION 25�80.7NT EMPLOYEE AND THAT I AVE <br /> OF <br /> REPORT DATE CASES THE HEALTH ANT <br /> OM M ZD D �v v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> (2o9) y b¢-3-{2S' <br /> m <br /> 0 REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANYWC OR AGENCY NAME 1 y {- <br /> LOCAL AGENCY ❑ OTHER a ` �oq �i� L o4c ( �Cc,t l(^ ��5�✓:�1 <br /> a <br /> ¢ ArDDRESS I1 I n \ e <br /> i(O�� F 11q�G�1'�`�1 Y. O_ �f77c Zo�S }�cl�`+ C �` cl SL.oI <br /> STREET cry STATE ZIP <br /> NAME CONTACT PERSON PHONE <br /> z� 1=kke� ❑ UNKNOWN �G✓r �ow� (Zw) Fl�J -2 }� <br /> S¢ <br /> as ADDRESS ^_ <br /> ¢ 'iG <br /> w `G1 1 STREET SCITv STATE �-1ZP3 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o ✓a.� Ckko. #�` ^t✓✓ �od`� (2c9) �IS-2�J',o <br /> ADDRESS <br /> cz S33 So <br /> 2 �� 50 q ; <br /> �J I J�.� � �o ,i's'aEEr c�c� � ca�iNW ZIP <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL ❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS 'FAIL FUEL STATION <br /> E]RESIDENTIAL a OTHER FARM [::] OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> wU �a... ��q .:,•-� �Ouc,� �}2�i11'� �S1✓� La,.v; -�'Y-�l\G� (Z�i) q(G�- <br /> W <br /> w REGIONAL BOARD PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> 0 Lij �✓o1�✓v.-. c\✓o C�,✓�i0..,5 — L?4-tiNRNOWN <br /> J <br /> 0 (2) <br /> h ❑ UNKNOWN <br /> r DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z f� <br /> M s M ( D D �v y ❑ TANK TEST TANK REMOVAL O OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w M M D D Y Y <br /> p HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> 0YES [�IF YES,DATE M MI DI D y y ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> DF--] TANK LEAK dUNKNOWN GAL. FIBERGLASS OVERFILL E:] RUPTURE/FAILURE <br /> Cc ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ TINRNOWN <br /> ❑ OTHER a UNKNOWN OTHER SPILL OTHER <br /> w w CHECK ONE ONLY <br /> UUNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F <br /> � CHECK <br /> zON ONLY <br /> w a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> L) ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Oz ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU)` ❑ NO ACTION REQUIRED(NA) `❑ OTHER(OT) <br /> J�� ` COQ.-F c,w���n�lTo�, r\o��c5 dv✓:.y Vo1wTcry s �SSeSS�^Q <br /> z J J <br /> w <br /> 8 <br /> HSC 05(4/87) <br />