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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° <br /> YES P1O REPORT BEEN FLED? ❑YESNO I.HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ REPORTED THIS INFORMATION.TO LOCAL OFFICUII.S PURSUANT TO SECTION 25180.7 OF <br /> REPOOM, ✓M � � �r��R CASES THE H rD�UNISCOOE ^ <br /> SmI . �J GATE <br /> NAME OF INDIVIDUAL FLING REPORT <br /> PHONE <br /> m <br /> ��J SIGN,► � <br /> O REPRESE ING ❑ OWNERIOPERATOR REGIONAL BOARD COMPANY OR AGENCY N E n <br /> pLOCAL AGENCY Q OTHERl ,,C // �{� �J C.L <br /> 2 ADDRESS tiV �✓X / <br /> TREET �r <br /> NAME CONTACT PERSON BATE zip <br /> F 6� i // PHONE <br /> a ! s� a / � ❑ LINKNowN <br /> ADDRESS <br /> Lu <br /> cc <br /> ctrr STATE Lp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Q h `fit /oCC L�l h S o to t�0�/)'f6 5�SG7� <br /> ADDRESS <br /> . a.o(�,v <br /> STREET coup P <br /> 0 CROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS J2 RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARMp THER <br /> LOCAL AGENCY AGENCYNAMECONTACT PERSON PHONE <br /> w <br /> I.CL <br /> REGIONAL BOARD PHONE <br /> c- R C ( ) <br /> w (I) , NAME OUANT(TYLOST(GALLONS) <br /> 2;4wNOWN <br /> 0 (2) <br /> N <br /> ❑ UNKNOWN <br /> ► DATE DISCOVERED HOW DISCOVERED <br /> III Q` ❑ INVENTORY CONTROL ❑ S BSURFACE MONITORING NUISANCE CONDITIONS <br /> w 3M � (� q ❑ TANK TEST ❑ TANK REMOVAL OTHER ��,,.. <br /> o r r !-t �i0�1(LG(� ) /l(4 C/J t�iti51 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) �/I <br /> (� 1:1UNKNOWN ❑ REMOVE CONTENTS ED REPLACE TANK a CLOSE TANK <br /> w <br /> M 0013'.1 Er r <br /> O HAS DISCHARGE BEEN STOPPED 79 ❑ REPAIR TANK PAIR PPNG a CHANGE PROCEDURE <br /> o <br /> [2---YES [:] NO IF YES,DATE Ll <br /> ` MI �o �oI � ?r ❑ OTHER <br /> rw SOURCE OF DISCHARGE TANKS ONLYACAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURESALURE <br /> PIPING LEAK AGE YRS ❑ STEEL CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> va <br /> ❑ UNDETERMINED IEJSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> 2 m <br /> cc <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> v�' ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESSAVALAB NO FUNDS <br /> ❑ LE 7D PROCEED [:] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 4❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) Q ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> 7::::I`/e re v S to 3 ng CY7` a 5712 <br /> of <br /> � r`cu,�7Zc.P� .fir f..e Q ssesS'G�ti�7S Grl=t��,�2 'o;, <br /> a/,R�� � <br /> 171 <br />