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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/C,ONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YESNO REPORT BEEN FLED? ❑ YES ,.�/Np REPORTED <br /> CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO.LOCAL OFFICIALS PURSUANT.TO SECTION.251W OF <br /> REPORTDATE [/ CASE THE HEAL AN SAFTY <br /> U�M M d / DI q 10 Y SIGNS G <br /> NAME OF INDIVIDUAL FILING REPORT E <br /> PHONE T_t�VLi S� SIGNA�TUnRE // <br /> 0rnn ,ll 7r 9ir k, <br /> O REPRESENTING <br /> F OWNEFVOPERATOR ❑ REGIONALSOARD COMPANY ORAGENC/YNAME <br /> p ❑ LOCAL AGENCY ❑ OTHER ! A t f Cir C M N/� <br /> ADDRESS ,+ <br /> J <br /> /390 W.'//0(4) Puss R( TS 9c)U Concord C/} qXfap <br /> STAEE <br /> j NAME OTY STAZIP <br /> CONTACTPERSON PHONE U <br /> D 1 ❑ UNKNOWN • /— of X, / <br /> a a Lind k,st t )��y <br /> < ADDRESS <br /> Wal /+5 adL`✓c Of <br /> P. 0. 8vx No ? Coneollot C�4 9Xsay <br /> FACILITY NAME(IF APPLICABLE) !'l / OPERATOR cm STATE rn!PHONE/�� / J "TN T�IU t^ y' C) �rrl ✓i �N�n\C�- mo <br /> a ADDRESS i) <br /> 3011 acr� ub;r. Ha l� S¢veSnnTca a; . <br /> 9sav9 <br /> y CROSS STREET ap <br /> TPE OF AREA COMMERCIAL❑ INDUSTRNL ❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> ❑RESIDENTIAL Q OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY <br /> AGENCY NAME <br /> y, CONTACT PERSON PHONE <br /> SAn Toa A;+� CO, Er J,ro,MeV&l ✓�fa� C o (aoq) 1{(0�3yae <br /> w REGIONAL BOARD P <br /> 1 <br /> I Irk( V Gt l 'C� PHONE <br /> w O NAME ;G)UANTrry LOST(GALLONS <br /> �,. S rn S C?C fa l�rv'r Get /. )n UNKNOWN <br /> �O1 ti <br /> N� <br /> ❑ UNKNOWN <br /> i DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL <br /> w ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> TANKTEST ❑ TANK REMOVAL OTFIER LJ�� 1 <br /> M M DD 0 11OY ❑ lYn <br /> DATE DISCHARGE BEGAN I I (y// METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D D r r LJ UNSOWN ❑ REMOVE CONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED? REPAIRTANK � REPAIRPPING ❑ CHANGE PROCEDURE <br /> S ❑ YES ❑ NO FYES.DATE MI MI DL_Dl yl Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY ACITY(()) MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN /� �()A4 a—j}A ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFAILURE <br /> ❑ PIPING LEAK AGE _YRS ERrsTEEL ❑ CORROSION Fp-*u`NKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER <br /> ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> �a <br /> _ ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKWGWATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Zy <br /> ¢� ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PgOGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uy �NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> w ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(TD <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(G7) ❑ REPLACESLIPPLY(RS) <br /> ( 1 i <br /> ❑ <br /> TREATMENT AT HOOKUP(HU) �'p❑ NNO,ACTION <br /> -REQUIRED INA) /may //)OTHER(On- -r�U !FL �f`/2/�/t4 A'P� <br /> H �-6(10'7 QSd(_.SJ/,�1C�I� /. t `X ' �,a <br /> /J 7 Oi1C�.L 4r G07 �� 6�� Ci Aa 664,t-e CC <br /> nxm(ae <br />