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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)f CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY:USE ONLY <br /> YES No <br /> REPORT BEEN FILED? [::]YES 0 NO I HEREBY CERTIFY THAT 1 AW AAESIGNATED GOVERNMEk EMPLOYEE'.AND THAT l EiAVE' <br /> -REPORTED THIS INFORMATION.TO LOCAL:OFFICAALS PURSUANT T0-SECTION 25100.7 OF <br /> REPORT DATE CASES THE HEALTH AND SAFTY CODE <br /> 0-19-1 D 2 D ?yl V SIGNED DATE I. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ec�a lertie, I k.ss fad) AF <br /> 0 REPRESENTING 0 OWNER/OPERATOR F7 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> n¢O 1p LOCAL AGENCY OTHER 15-T .�L 11 G �����. rJ i�e C-n v. f1�( <br /> ¢ ADDRESS <br /> (��y� �//��f l^7 A 1 (/•]��yII�/ <br /> •O "' �/^'0 I STREET S�6 c-a�,v CITY �7 + STATE 21P <br /> NAME <br /> Z � � CONTACTPERSON <br /> IQ� UNKNOWN �oLrfe f-Q PHONE <br /> �aZ-9—v71 <br /> R< ADDRESS <br /> w <br /> W �v 5 un►o cr s '}- AE ve . ;50-Q 1 rA-yKeA <br /> CIT' (?A STATE 5O 21P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> = 7 �-�-�u —/ w Anfw)a,r� �-f�Isa - r t1�3` -a3a. <br /> Q <br /> !Z ADDRESS <br /> �/( T /f 1A <br /> W • O v v �'SiR✓tET Wn 1 e 1..�' orry V o`"�. ("t I',1 COUNTY V� P <br /> y CROSS STREET TYPE OF AREA OCOMMERCWL INDUSTRIAL Q RURAL TYPE OF BUSINESS RETAILFUELSTATEON <br /> Q RESIDENTIAL Q OTHER O FARM ® OTHER [�veY)12v►C,e <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> S •S. 4�,bl�c, H&A kSerJ� <br /> W W U. ons a. �C>n�n ) <br /> w REGIONAL BOARD <br /> CL !PHONE <br /> � 1 <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> J UNKNOWN <br /> (2) <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED � INVENTORYCONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Lu M 3 M Olo 6 y y TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Lu M M D Di yl yl ® UNKNOWN REMOVECONTENTS REPLACETANK a CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> p YES NO IF YES,DATE M M D1 011 y ® OTHER Lt,V1 K,V%0LL)A) <br /> N SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> 0 TANKLEAK -K UNKNOWN GAL. FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION Zj UNKNOWN <br /> O OTHER ® UNKNOWN OTHER SPILL 0 OTHER <br /> W W CHECK ONE ONLY <br /> UNDETERMINED 0 SOIL ONLY 0 GROUNDWATER [::] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> z0 <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U NO ACTION TAKEN [�j POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> QF7 SITE(CD) 0 EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) [71ENHANCED BIO DEGRADATION(11) <br /> 2 F-� CONTAINMENT BARRIER(CB) 0 EXCAVATE 6 TREAT(ET) PUMP&TREAT GROUNDWATER(GT) 0 REPLACE SUPPLY(RS) <br /> O TREATMENT ATHOOKUP(HU) a NOACTIONREOUIRED(NA) ® OTHER(OT) <br /> U.L. q �1 U e- <br /> CXAQ <br /> ui <br /> HSC05(W) <br />