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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 /> ❑ O THAT I HAVE <br /> YES NO <br /> REPORT BEEN FLED T []YES NO REPORTED THISY THAT I AM NFORMATIONATO DESIGNATED <br /> OFFICIALSNMENT PURSUANT LTO S CTION 25160.7 OF <br /> REPORT DATE CASES THE NEA,L`Jyi A,ND SAFfYCODE ��-2 �/! I . <br /> Y SIGNED DRE ` <br /> NAME OFIAII L-1,1, <br /> Alt- SPORT f f � (�PHONE � SIGNATURE <br /> Lei ll.. JATOR <br /> REPRESENTING ❑ OWNER'OPEMTOR ❑ REGIO LBOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHERIh <br /> ¢ ADDRESS <br /> 0 ) 1l STAEf OL/ �l CITJL[/� �' -y ATE <br /> NAMECONTACT PERSON PHONE <br /> S� ❑ UNKNOWN %N�/G / J3G/-OGi <br /> dADDRESS y /�/J �L/\�/�/'J <br /> IAI <br /> FACILITY NAME IF APPLICABLE) 9PERATOR PHONE <br /> ADDRESS G„ J7�CK laJ�f ��ZUV <br /> CROSS STREET ` TYPE OF AREA a COMMERCIAL X INDUSTRIAL RURAL TYPE OF BUSINESS �C�Yi RETAIL FUEL STATION <br /> _tIj ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALA /vr�j 10GA �E CONv/PERSONP <br /> REGIONAL BOARD K K// PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> vk d ro dA9.gu nIS UNKNOWN <br /> (2) <br /> 3' ❑ UNKNOWN <br /> DATE DISCOVERED o �r Y NOW DISCOVERED <br /> WC ❑ INVENTORY CONTROL E] SUBSURFACE MONITORING ❑aVO./NUISANCE CONDITIONS <br /> U ❑ TATEST ❑ TANK REMOVAL 2q OTHERL(,�v�tA' rG�'N+ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> }5w <br /> MI MI DI DI v UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HAS <br /> OP <br /> Q ❑SYSR❑END TFYES,DATE u u o o r v OTHER REPAJRTAN 4-EPAIflPIPWO ❑ CHANGE PROCEDURE <br /> SOURCE OF DISCHARGE TANKS ONLY.CAPAGITY MATERIAL CAUSE( ) <br /> q ❑ TANK LEAK ❑ UNKNONN (y1L, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURUALURE <br /> ¢ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION xUNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHE EONLY <br /> KSITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CM SITE(CO) ❑ E%CAVATE6OLSPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) EN ED I AT (IT) <br /> ❑ CONTAINMENT 13ARRIER ICE) ❑ E%CAVATE6 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) (RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NOACTOJREOUIRED(NA) OTHER(OT) <br /> �n/ �o,eiv)EO Du✓iAIF� /'�/oi'ese�fa. � ✓�:. hit ).e ,ei� Ste; <br /> s,),��,p G�.vJ �L`cd Possib/� si�e. .ySsesS�n�vA� w�GG r'fuiQZJ m/� CC)n/7R i'7 i�l/sr7'i o i✓ - <br /> I�uuslwR <br />