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- <br /> `�: <br /> ZA-54 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)l CONTAMINATION SITE REPORT �. <br /> EMERGENCY -HAS STATE OFFICE OF EMERO CV SERVICES FOR LOCAL AGENCY USEONLYY El <br /> YES NO REPORT SEEN FILED ~ FS (HER Fg ;CERTIFY THAT I AM a I�P$IGNAt>~U t�QV iFQ Ni ��ipCt'>�I k J�N� N11��7 Hht <br /> <<fiEPO b THIS INKORMATIONJO LOCAL CIFFIMA PUASUAN1 tO,S�CtlON 2516�P OK <br /> RMRT� I �- ,�v� Y CASES �< � •,,, t THE, <br /> N D. .� �APTY <br /> �D <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> rs.�•_�� �,�-- <br /> REPRESE ING � OWNEWOPERAfOli REGIONAL BOARD COMPANY OR AGENCY NAM <br /> nAL AGENCv OTHER --- JQZ7� rC7 u/ �J C1O C / yC �' ��J'V'/ <br /> ¢ ADDRESS /7ae. /L t, <br /> 9TREFT CITY STATE �' Q <br /> NAME <br /> CONTACT PERSON / PHONE <br /> W e l�d C`'�t u r>c-�-. El UNKNOWN �✓ e l GL(/YU !�u rG� (({i <br /> ADDRESS <br /> �ayo sje M/14e. l�'c� Ser k/e CfJ- X707 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a, resl`den c- rt' �/�/Q!d�-r Chu"C (ao?)935-a3�y <br /> ADDRESS rr/ <br /> Ile deo y 7W q G!/ S'a-rr o �: `_��_�53 <br /> 9TFEET -. CITY WON- <br /> f,. W CROSS STREET TYPE OF AREA TYPE OF BUSINESS <br /> y �COMMERCIAL O INDUSTRIAL �RURAL M RETAILFUEL9TATION <br /> Ho ll r• RESIDENTIAL F7 OTHER EDFARM M OTHER <br /> LOCALAGENCY 1 AGENCY NAME <br /> / CO1NTAACTPERSON /� y PHONEFt w <br /> y -4 t�Cs�fl_�_- Ct L�LTJ �s ^r�C 1LLc LC 1� i l�0 ( GC dC_`' �) ✓7 3 <br /> y REGIONAL BOARD PHONE <br /> (1) NAME OUANTITY LOST(GALLONS) iy <br /> h I�Q L�__ UNKNOWN <br /> _ UNKNOWN <br /> DATE DISCOVER/ED, cc� HOW DISCOVERED 0 INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> ©M 8 rd1 ( p ✓p � Y Y n TANKTEST Le-°fANK REMOVAL 0 OTHER <br /> bAT'E DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> .1 ml bl Y1 Y (---� <br /> HAS DISCHARGE BEEN STOPPED 7 LJ REPAIR TANK REPAIR PIPNG ❑ CHANGE PROCEDURE <br /> -[i�S [::] NO IF YES,DATE MI MI DI bl Y Y O'ER <br /> SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK d UNKNOWN 00 GAI, O FIBERGLASS <br /> OVERFILL' RUPTURE/FAILURE <br /> r' <br /> O PIPING LEAK AGE YRS I?-`;'T-EEL CORROSION �NOWN - <br /> OTHER UNKNOWN OTHER SPILL OTHER <br /> CHECK ONE ONLY <br /> �UNDETEpMINED a SOIL ONLY a GROUNDWATER a DAINKNd WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKO ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F7 CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED On UNNECESSARY) <br /> y NO ACTION TAKEN a POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> CAP SI?E(CD) O EXCAVATE 3 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BK)DEGRADATION(IT) <br /> O CONTAINMENT BARRIER(CB) O EXCAVATE b TREAT(ET) PUMP 8 TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTON RECUIRED(NA) OTHER(OTT <br /> al r o C,,6-, r b o ri ©cl o r, Y► o f e cl a 7`,'i'r e, o -F 'Sal-pr p/i n <br />