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I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE ICOR LOCAL'AGENCY'USE ONLY <br /> YES NO REPOATffEEN F ? O.E. t•HEREBY CEF3TIFY`THArjil" A t?E51c lA?ER G[31F�RN►AEFFF EMPLOYEE AN[3 f J1T E tfA1tE;. <br /> -J ,ftEPOR1E ."C, Its t?RhtNTit t T :LDCAE Flcros PE3R�CIAA#�TtS 25t8�1 DF <br /> REPORT E <br /> ATE CASE* THE TH ANTy <br /> X j <br /> NAME OF INDIVIDUAL FLING REPORT PHONESIGN TURF <br /> m <br /> ,, a- • <br /> REPRES ING �..OWNER(OPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCALAGENCY O OTHER <br /> ADDRESS j/}1 <br /> STATE <br /> w NA t. C CTPEMON PHONE <br /> m(Nompu <br /> -ice )3� -3s <br /> a AddRE <br /> im <br /> FACIL TY NAME IF. <br /> ApALiCA81LEy .. OPERATOR f"�IdNE Cs� <br /> ADDRESS... <br /> P <br /> C SS STREET TYPE6F AREA,rlCOMMERCIAL Q INDUSTRIAL RrAURAL T'YPEGIFBUS"- <br /> BETA FUE1 STATION <br /> 3 fkde RESIDENTIAL OTHER FARM OTHER <br /> LOCALAGEIfCY AGENCY NAME CONTACTPERSON PHONE <br /> UL <br /> AEGIONXL BOARD PHDNE: <br /> (1) NAME QUANTITY LOST(Ci <br /> X li.r�y+ i ✓� UNKNOWN <br /> AA <br /> ° (2) <br /> ,UNKNOWN <br /> i DATE DISCOVERED HOW DISCO RED INVENTORY CONTROL SUBSURFACE MONITOR NG n .;NUISANCE� <br /> u *ra M o a v r TANKTEST TANKREMOVAL OTHER <br /> I <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY1 <br /> M M a o v t+��1 KNOWN REMOVECONTENTS � REPLACE TANK CLOSE TANK <br /> p HAS DISCHARGE�E TQPPEDDAT� � � �� � a Y Y � (OTHER TANK: REPAIRPIP�G � CHAFIC�EFROCEOURE <br /> NO <br /> us SOURCE OF OISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAKUNKNOWN ti+' GAL: ❑ FIBERGLASS COVERFRI. RLTUAEIFAiLURE <br /> El PIPING LEAK AGE YRS TEFL � CORROSI NUNKNOWN <br /> E] OTHER 5?-UN f OTHER � SPILL Q OTHER <br /> ww <br /> CHECK ONE ONLY <br /> V:1 UNDETI RMINED C SOIL ONLY E] GROUNDWATER [-] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AF ECTIM <br /> M <br /> CHECK ONE ONLY <br /> z� <br /> F SITE INVESTIGATION IN PROGRESS(DEFINING ExTENT{r PROBLEM) M CLEANUP IN PROGRESS o SIGNED. (CLF-ANUP C.f)MPLETEDOf UNNECESSAFIY) <br /> NO ACTION TAKEN L] POSTCLEANUP MONITORING IN PROGRESS E:l NO FUNDS AVALAS1.2 TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br /> CHECK AFPROPRIATE.ACTION(S((SEE BACK FOR DETAILS) <br /> CAP STTEgCO) lXCAYATF&DISPOSE(ED) CD REMOVE FREE PRODUCT(M Q ENHANCE DBIO DEGRADAT*N(m <br /> 50 -2 F CONTAINMENTBARRIERtC$O: a .€X(OAVATE&TREAT(ET) Q PUMPS' <br /> UMP lr TREAT GROUNDWATER(GT) REPLACEStPPLY(RS) <br /> TREATMENT AT HOOKUPOM NO ACTION REQUIRED(NA) � OTHER(OT) <br />