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e . <br /> n UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT(HAVE <br /> ❑ YES ❑ No ❑YES ❑ NO REPORTED THIS INFORMATION TO LOCAL;OFFICIALS FtlRSUANT?O SECTION 25180.7 OF <br /> REPORT DATE CASE X THE HEALTH AND SAFTY CODE <br /> M M D �Djyj Y SIQNED :' DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> nn <br /> DeGraag <br /> o REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ❑ LOCAL AGENCY ❑ OTHER <br /> a <br /> ¢ ADDRESS <br /> STREET CITY STATE ZIP <br /> w <br /> NAME CONTACT PERSON PHONE <br /> m� ❑ UNKNOWN <br /> g�,' ( ) <br /> co <br /> a ADDRESS <br /> LLJN.it. 3tr.c '3U6a IL-19.3 7000 Easy_ AVenue <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z ( ) <br /> O <br /> ADDRESS <br /> 'J STREET CITY COUNTY ZIP <br /> LLJ <br /> ~ CROSS STREET TYPE OF AREA ❑COMMERCIAL E] INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> a5 <br /> ❑RESIDENTIAL ❑OTHER _ ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z w ( ) <br /> zLu— <br /> w REGIONAL BOARD PHONE) 6 <br /> a a <br /> (t) NAME QUANTITY LOST(GALLONS) <br /> w p ❑ UNKNOWN <br /> LU <br /> Q J <br /> ~O (2) <br /> `D ❑ UNKNOWN <br /> N <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> F M M D D Y Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M D D Y Y <br /> ❑ UNKNOWN ❑ REMOVE CONTENTS [:] REPLACE TANK E:] CLOSE TANK <br /> M <br /> pHAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK El REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o [7] YES ❑ NO IFYES,DATE M M D D Y Y ❑ OTHER <br /> wSOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> cl)U ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> El PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> cc <br /> 2 ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> a <br /> U� ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> z� <br /> Lu <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr< <br /> U ❑ 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 /> O ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) El REMOVE FREE PRODUCT(FP) El ENHANCED BIODEGRADATION(IT) <br /> 50 <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) E] REPLACE SUPPLY(RS) <br /> Cc ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) 1 - <br /> z <br /> z <br /> 2 <br /> 2 <br /> 8 <br /> HSC 05(4/87) <br />