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UNDERGROUND STORAGE I HNK UNAUTHORIZED RELEASE (LEAK) /CONTAf0INATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO REPORT BEEN FILED If-�YES n NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT j HAVE <br /> l_J _ REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> FIE <br /> POR f DATE l CASE x THE HEALTH AND SAFTY CODE <br /> /GD DI vJ Ov SIGNED <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE �,�� SIGNATURE <br /> o REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ LOCAL AGENCY OTHER �^ <br /> ¢ ADDRESS <br /> STREET CITY <br /> STATE ZIP <br /> NAME CONTACTPERSON <br /> PHONE <br /> Z,r �sy / ! O/ C_ . ❑ UNKNOWNj(-Y� <br /> �a ADDRESS <br /> cc <br /> �, o . fox 4oz3 cr�,cic ,b c �4�2¢ <br /> STREET CITY <br /> STATE PP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> PHONE <br /> �cd � STS'/�,Slotb .i, lcb�icCc - ( j°J�a2 '/ <br /> a ADDRESS / <br /> FW- STREET CRY COL/M.y, P <br /> CROSS STREET TYPE OF AREA COMMERCIAL a INDUSTRIAL a RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �7 �D /1/i� <br /> Z <br /> w <br /> IL <br /> w0 REGIONAL BOARD PHONE <br /> a¢ <br /> y (�1 NAME QUANTFTYLOST(GALL.ONS) <br /> UNKNOWN <br /> O (2) <br /> U3 El UNKNOWN <br /> i DATEOI/SfCOVERED HOW DISCOVERED WVENTORYCONTROL ❑ SUBSURFACE MONITORING a NUISANCECONDFTIONS <br /> Z3 D "9'y v ❑ TANK TEST F-1TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w t►M M D o r r I UNKNOWN dREMOVE CONTENTS a REPLACE TANK a CLOSE TANK <br /> p HAS DISCHARGE BEEN STOPPED 7 //�� ❑ REPAIR TANK REPAIR PIPING a CHANGE PROCEDURE <br /> a BYES ❑ NO IFYES,DATE �I 2Mi 2D V DI�9r O r ❑ OTHER <br /> Lu SOURCE OF DISCHARGE TANKSONLYiCAPACITY MATERIAL CAUSES) <br /> TANK LEAK a UNKNOWN Ili,GAO GAL ❑ FIBERGLASS a OVERFILL ❑ RUPTURE/FAILURE <br /> O¢ ElPIPING LEAK l AGE YRS STEEL E:1 CORROSION UNKNOWN <br /> ❑ OTHER SLI/ ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> (n a <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z y <br /> ¢a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢P <br /> U h ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 460 z ❑ CAP SITE(CO) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 8K)DEGRADATION(IT) <br /> 2 a CONTAINMENT BARRIER(CB) a EXCAVATE 6 TREAT(ET) a PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY(IS) <br /> Q TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(On <br /> Az-c_ 7AA11,1-S 4,S(,b 7DF E ,��� tic!/T.} bOI/,SGE V-64 <br /> �4 <br /> �gE,�CrcSS t=HITT/.cls' �� � o�r��E�SS vSCiTiE� ✓.A,�jot�S <br /> �37r � /4{. l� .�-ssac, ,4+�1� •� x�S <br /> HSC 05(W) <br />