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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> E]- YES EK NO REPORT BEEN FILED 7 E]YES NO i HEREBY t�RTIFY THAT I AMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT l HAVE <br /> - REPORTED THIS INFORMATION:TO LOCAL OFFICIALS PURSUANT TO SECTION 25180,7 OF <br /> REPORT <br /> pDATE7a CASE x THE HEALTH AND PTY CODE. <br /> D v v SKWNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA FTE <br /> �'T—cd,T 01b)372-1-/700 waa' <br /> o REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> w 1 <br /> p LOCAL AGENCY OTHER �hU, Ld.�5,�L'' F l uo r D ave 1 t ` GT Z <br /> ADDRESS <br /> 1401 tAak'l."' . bety't SuAt 14.o' Wask Sacra*e-k4o ) GA 956 91 <br /> STREET CRY STATE ZIP <br /> Lu NAME <br /> CONTACT PERSON PHONE <br /> TkQ SoDUNKNOWN (2t� <br /> )'2S1- g15SvkBolo OeV - <br /> a ADDRESS <br /> Lu ict033 IlJesk ULlley Rwy ,i sui}t'i -loy Ken4l WA. 'M03Z <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o S� Lland -5 Iove# Icm6 - Clty?-vx /Vlav\ Guepoal &rt+A3c'l (209)2.3 q- 325Z <br /> < I ADDRESS <br /> 1311 Qur� �AaiK 5�•rce� MuK�Ca , CA. Sa•,��a-TO�n 9'5336 <br /> W STREET CRY COUNTY P <br /> H CROSS STREET TYPE OF AREA EjKCOMMERCiAL ❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS Epf RETAIL FUEL STATION <br /> V�04 A.m Dy" ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wwU SGh3oa ugh tw��y P0bikcileal Seruic¢s Robert/ M9) q6$-1)332 <br /> w W REGIONAL BOARD PHONE 255- <br /> 3DDO <br /> a.i Cen�rwl Vklto i2� ,o:i C S acrktiv K�b v ice Tie*%T k xye-r (41(p ) 255- 3i33 <br /> N (�) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> �" Cj GSD l i4e _ UNKNOWN <br /> J mm <br /> �> (2) <br /> N z <br /> UNKNOWN <br /> Lu <br /> GATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> OMM D 9 D 1,1 b y ❑ TANK TEST d TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN Fes( METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D D v v I I UNKNOWN ❑ REMOVE CONTENTS REPLACE TANK ❑ CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p n YES E� NO IFYES.DATE M T D D v r U OTHER IepL 4c7AAIL.), f Kes, aj vl`+Spehsers <br /> rw SOURCE OF DISCHARGE TANKS ONLYr-APACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ll� UNKNOWN 10k- 10k 6k GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE V N k(W W N YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHERSPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> d <br /> v ❑ UNDETERMINED Ek� SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONF ONLY <br /> zN <br /> ct a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> U NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED lj� EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z F-] CAPSITE(CD) EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 0o <br /> ❑ CONTAINMENT BARRIER(CB) EXCAVATE 8 TREAT(ET) ElPUMP d TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> i olivr�►'.n.� Y`twnoi""l 'Ip UST`i i wtpKt-4-d ayk be ��y mk r)K/ kru� �tnutt ynscr�ti' <br /> z ®� soil F��n �uN k pts re weal i,� -a s:ke fir pu sKl. l_ <br /> �v c�V»iuAG�lvx �er p�j 5e✓1}�r� tvt jJi1 n-F 12�} 0r TK pub iwlQ �x 1 /lace fOtlOwG✓yc° . <br /> I <br /> HSC 05 w/+n <br />