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LL - qIo uyj <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED? ❑YES NO 1.HEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE'AND THAT{;kAVE <br /> REPORTED:THIS INFORMATION:TO LOCAL:OFFICIALS.PURSUANj TO SECTION 251807 OF <br /> REPORT ATE CASE# THE �App04ANDSAFTY <br /> .�M MISIGNEDr <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN j`�RE <br /> m COMPANY OR AGENCY NAME <br /> w REPR SENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br /> LOCAL AGENCY ❑ OTHER (J I7//� �� / <br /> a <br /> w -k-2 <br /> ADDRESS <br /> STREET CRY STATE ZIP <br /> NAME ( J c CONTACTPERSON <br /> r PHONE <br /> f C/ q <br /> N¢ l ���0/`� V J ❑ UNKNOWN 7-0 'Y /iV U <br /> < <br /> ADDRESS <br /> La <br /> Z ! L% 1_ I N v S R' EET Lu IO/l.( a// ' /�'' e'17`1 O/`' CRI' STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR /1" PHONE <br /> Q , c�itJ (J'SA / /i /''tib c. (22=i) 427 4& Z1 <br /> t ADDRESS �/Jy� <br /> w C STgEET CRY COUNTY 23P <br /> y CROSS STREET TYPE OF AREA QOMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS PKI RETAIL FUEL STATION <br /> l` a ! r�ci 7L ❑RESIDENTIAL E::]OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON /• PHONE <br /> Lu <br /> w w REGIONAL BOARD l PHONE <br /> IL <br /> (1) NAME QUANTITY LOST(GALL.ONS) <br /> H <br /> O <br /> j / UNKNOWN <br /> 0 (2) <br /> UNKNOWN <br /> z <br /> DATEDISCOVERED �j / HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w L%M `�M / 1 D D /v (o Y ❑ TANK TEST TANK REMOVAL OTHER <br /> IDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w M M O D Y Y <br /> p HAS DISCHARGE BEEN STOPPED? l// REPAIR TANK dR,EPAIR PIPING ❑ CHANGE PROCEDURE <br /> pYES ❑ NO FYES,DATE ,:MI ` M ��D o �--'v O- OTHER,%[.[�i�'y,�I-`.. <br /> w SOURCE OF DISCHARGET//A��NKhhS��ONIYICA�P�AC�ITY MATERIAL CAUSE(S) <br /> Q TANK LEAK UNKNOWN /l/�l��;i �� C GAL. Q FIBERGLASS a OVERFILL Q RUPTURE FAILURE <br /> ❑ PIPING LEAK AGE YRSSTEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER S UN_i(NOWN ❑ OTHER ❑ SPILL Q OTHER <br /> w a CHECK ONE ONLY <br /> U I ❑ UNDETERMINED SOIL ONLY a GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> y <br /> �c ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 2 t <br /> U rn ❑ 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 /> 0 4 CAP SITE(CO) EXCAVATE d DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <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 /> r c- <br /> � <br /> z <br /> w i i ���' ; Y c.�jC.- r��� i/}`i.✓ �. l i' , E L•�( J <br /> wQ �. ✓✓ <br /> t, <br /> HSC 05 IUEn <br />