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WA <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SEpE FOR LOCAL AGENCY USE ONLY 's. <br /> ❑ YES NO REPORT BEEN FILED ? OYES NO 1 HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I"HAVE <br /> REPORTE�D THIS. INFORMATION TO LOCAL OFFICIALS P PURSUANT TO' SECTION 35180.7. OF- <br /> REPORTDATE CASE # THEH TH AND SAFTY D - <br /> 7 .7 ✓wr4 r <br /> OM 6o CJrZ2 L <br /> 5 / y SGNED ; <br /> GATE <br /> NAI Mj OF INDIVIDUAL FILING REPORT PHONE SIGNAT E <br /> ii <br /> Te (,E?/ ( 2�ti ) y � 8 -31�c <br /> w REPRESEG ❑ OWNEfVOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p LOCALAGENCV ❑ OTHER <br /> ADDRESS arc <br /> /Dial E NFl ��Lr�,J l�u� c;j�cr(� C,y 75 05 <br /> STREET CRV SLATE ZIP <br /> m NAME ^ CAONTTACTPERSO/NN (PHONE <br /> m <br /> zw <br /> W G6j E�- NV/ ❑ UNKNOWN <br /> ADDRESS <br /> c7Y ,J <br /> uk <br /> FACILITY NAME (IF APPLICABLE) OPERATOfl PHONE <br /> tj O ADDRESS C <br /> ErL7��, N/ LC k0,)943 -�Ic/✓ � a7 � 95z�j <br /> y CRTSTR� crtv couKry aP <br /> TYPEOFAREA ❑ COMMERCIAL ❑ INDUSTRIAL K URAL TVPEOFBUSINESS <br /> ❑ RETAILFUEL STATION <br /> ❑ RESIDENTIAL ❑ OTHER ❑ FARM <br /> �qy LOCALAGENCY AGENCVNAME CONTACTPERSON PHONE <br /> 2wg LHS ( Ji g16s3c/Z � <br /> � w REGIONAL BOARD <br /> PHONE <br /> (11 NAME QUANTITY LOST (GALLONS) <br /> O w AS L UNKNOWN <br /> �< <br /> ❑ UNKNOWN <br /> W DATE DISCOVEREDJJ�� HOW DISCOVERED ❑ INVENTORYCONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M o 0. v Y ❑ TANKTEST ❑ TANKREMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> w M o o y y UNKNOWN ❑ REMOVECONTEN75 REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN TOPPED ? ❑ REPAIRTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YES IFYES, DATE OTHER <br /> M Ml o o v v ❑ <br /> wSOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(5) <br /> ❑ TANKLEAK UNKNOWN GAL. ❑ FIBERGLASS <br /> ❑ OVERFILL ❑ RUPTUREiFAILURE <br /> ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION Ug--�OFKNOWN <br /> O OTHER UNKNOWN ETHER 1>rUAl6W ❑ SPILL ❑ OTHER <br /> w CHECKONEONLY <br /> Vw ❑ UNDETERMINED E20'BOILONLV ®GROUNDWATER Q DRINKINGWATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zw <br /> i a ❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS Q SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) _- <br /> U % ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACT)ON(S) (SEE BACK FOR DETAILS) <br /> 00 F-1 CAPSITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> w ❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE B TREAT (ET) E::] PUMP & TREAT GROUNDWATER (01) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER (OT) <br /> turf/L�r Sf� �s5ess.(a �L �vir! rc� u7 .��1 cI'ett� ��u ,i� E ! <br /> a <br /> Ks��,� <br />