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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENL,V. NLY <br /> ❑ YES ❑ NO REPORT BEEN FILED? [:]YES NO RHEEPORMTHICERTIFY:THORAMAi7A�ATO LIGNX OCAL OFFICI LS�SUEANT TO SECTION 25180.7 OF-: <br /> REPORT DATE CASE% THEH -fYCODE <br /> Z <br /> Q MI u CI v�Ky <br /> SIGNED ?64TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ❑ OWNER/OPERATOR ❑ COMPANY OR AGENCY NAME <br /> p REPRESENTING <br /> w REGIONAL BOARD ,OR / N <br /> LOCAL AGENCY OTHER <br /> a <br /> ¢ ADDRESS <br /> L / STREET ' � CfTY � � STATE ZIP <br /> CoNTACTPERSON PHONEw NAME ) 1/ <br /> UNKNOWN ( <br /> y n ADDRESS .// _ P <br /> ¢ i / STREET , / CITYauc4STATE ZIP f� <br /> FACILITY NAME(IF APPLICABLE) OPERATOR V PHONE <br /> ,»,v Fer+,vk L�aeh I (zv ) Q!5� <br /> �- ADDRESS <br /> i3 LL_, �/ ,,-� �� Cm 7r a� CCUNTr P <br /> CROSS STREET TYPE OF AREA a COMMERCIAL O INDUSTRIAL RURAL TYPE OF BUSINESS E] RETAIL FUEL STATION <br /> N I ❑RESIDENTIAL ❑OTHER FARM a OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 20 <br /> w 2 JAS J yr v �� ,si r - J��.�c �.����s� V09) <br /> �++ REGIONAL BOARD PHONE <br /> (I) NAME QUANTITY LOST(GALLONS) <br /> UZ p ❑ UNKNOWN <br /> Q J <br /> rp <br /> D (2) UNKNOWN <br /> rn <br /> z DATE DISCOVERED r� HOWDISCOVERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OMM Qo 0 1f v d v ❑ TANK TEST [�TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 2UNKNOWN REMOVE CONTENTS REPLACE TANK C OSE TANK <br /> M M o o v v ❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br /> Q HAS OISCH GE BEEN STOPPED? <br /> O I YES ❑ NO IFYES,DATE MI MI 0 oI v v ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIALCAUSE(S) <br /> �ANK LEAK Q UNKNOWN 400(2_GAL. FIBERGLASS OVERFILLa RUPTUREFAILURE <br /> PIPING LEAK AGE YRS E2--STEEL <br /> ��RROSION UNKNOWN <br /> ❑ OTHER a UNKNOWN ❑ OTHER Q SPILL OTHER <br /> w w CHECK ONE ONLY <br /> V Z ❑ UNDETERMINED ❑ SOIL ONLY I ri GRGROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> w ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F-1CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V H ❑ NO ACTION TAKEN a POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CO) F-1EXCAVATE6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) F7 EXCAVATE&TREAT(ET) PUMP 8 TREAT GROUNDWATER(GTLL),^, /� REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTION REOUIRED(NA) OTHER(OT) <br /> s� ewde a'�"°`df <br /> w lY y v,7 G�OYLmCLi� CLQ /�E�{�000ZIL/' <br /> RSCOS(4Mn <br />