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w <br /> NOERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) 1 CONTAININATION SITE REPORT <br /> EMERGENCY /� HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALCERTIFY <br /> CY THAT <br /> I ONLY <br /> Tuf pEPOgT BEEN FLED? 1 HEREBY AGEY THAT I AM A DESIGNATED GOVEPNMENT EMPLOYEE AND THAT I NAVE- <br /> ❑YES ❑ NO REPORTED'THIS INFORMATION TO LOCAL CFFCIAS PURSUANT TO SECTION 251807 OF <br /> ❑YES NO THE HEALTHANO SAFTYWOE <br /> REPORTOATE p CASEF -� GATE <br /> .PHONE <br /> NAMEOFr/WT•OIVIOUALFIINGpEPORT {�atJ7loY�3Yl�� <br /> COMPANY OR AGENCY NAME <br /> 0 REP RESE G ❑ OWNENOPERATOR ❑ AL REGIONBOARD <br /> LOCAL AGENCY ❑ OTHER <br /> ADDRESS / , / CAL <br /> '/��1 9s•,lU <br /> /Y/DI N�! _ I�/� OXY T(�G IG �I? If�P V TP <br /> CONTACTPEASON PMDtffi esu• 3 Ho <br /> NAME 33 ❑uNIWowN 70l9/� Gurr4 `"l ql,/- u <br /> go <br /> - <br /> a ADORESS 't / <br /> �" r flYlrrT�r /Y1 c-A. fon STATE ` /Y nv <br /> a ,. ._�. '• smEEr rm PHONE Cy/_3 YCi <br /> OPEMTOR <br /> FACILITY NAME IF APPLICABLE) L/�/J ��/_ 7 o 9v <br /> F ADDRESS <br /> ,57 ,�i7 • Imr�ZnJU <br /> SIRE • /.•. <br /> • jTYPE OF AREA ❑I,'(IMMERCLLL INDUSTRIAL RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> % <br /> CROSSSTREET <br /> [[ > - <br /> .. // r T/[� �•. ..... ..- ❑RESDEtffIA ❑OTNER FARM <br /> NTACT PERSON PHONE❑ <br /> LOCALAGENCY AGENCY NAME Sc>'yLC< CO .3yb� <br /> zw �/ D !C lI/ 6 PHONE <br /> w� REGIONAL BOARD <br /> $ v� <br /> 3 QUANTITY LOST)GAL <br /> NAME <br /> NNNOWN <br /> cl�WNOWM <br /> x Ben ZerlP MOWOLSCOVERED NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Z GATEDISCOVERED NK ❑ ❑ <br /> �+ ❑ TATEST TA REMOVAL OTTER <br /> J u u o o r v <br /> METHOD USED TOSTOP DISCHARGE(CHECK ALL TAPPLY) <br /> DATE DISCHARGE BEGAN / <br /> y OWN ❑ REMOVECONTENNTENTS. ❑ REPLACE TANAN K L��/CLOSE TANK <br /> a uI ml 01 P 'r r ❑ REPAIR TANK ❑ REPAMPPWG ❑ CHANGE PROCEDURE . <br /> p HAS DISCHARGE BEEN STOPPED t - <br /> a ❑ YES ❑ NO FYES.DATE u j I, o r r ❑ OTHER <br /> TANKS ONLYR�APACITY MATERIAL CAUSE(SI <br /> ? SOURCE OF DISCHARGE (,/�J /O'` (IAL ❑ FIBERGLASS ❑ OVERFILL ❑ RLP ALURE <br /> ❑ TANK LEAK UNKNOWN / . <br /> AGE. YRS ❑ STEEL ❑ CORROSION UNKAIOWN <br /> ❑ PIPINGLEAK UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> 1 ❑ OTHER <br /> ww CHECK ONE OM.Y <br /> F-1 UNDETERMINEDSOIL ONLY ❑ GROUNDWATER ❑ ORINKNGWATER• (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AF <br /> FEGTEOI <br /> CHECKONEONLY <br /> a� ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENTOF PROBLEM) ❑ CLEANIP MPROGRE53❑ SIGNED OFF(QEAWPCOMPLETED OR UNNECESSARY) <br /> EVALUATING CLEANUP ALTERNATNES <br /> ❑ POST CLEANUP MONITORING IN PROGRESS ❑ ND FUNDS AVAILABLE TO PROCEED <br /> C:] NO ACTION TAKEN ❑ <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ENHAD BIO DEGRADATKIN(IT) <br /> j ❑ CAP SITE(CD) ❑ EXCAVATE L DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) [3NCE <br /> 5 TEp ❑ PUMP A TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(AS) <br /> F-1EXCAVATEATPEA ( <br /> i� CONTAINMENT BARRIER(CO) ❑ , <br /> ❑ TRFATMENTATHOOKUP(IAI) ❑ NO ACTION REQUIRED MA) ❑ OTHER(01) <br /> G[✓�rf{L!T SHIP aYss�rsrT.in� rer�u/!Ya/ ><Oore7`C4r,,..� nCyli., <br /> Cartllirn.nu�s�rn a5 A-l!` u/r(t/ !may n/'�rvP.-,�.�+C��l, [y, <br /> 7/0 -1/16[reA cr 5%/r' of cvr�GT. pF A1yrtle •r F%hP �. <br /> I � MSCiSINII <br /> 1 p <br />