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V UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> b EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> 0 YES NO ❑YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> EPORT ATECASE#9 THE HEALTH AND SAFTY CODE <br /> M M o v / - a 7 SIGNED DATE <br /> NAME INDIVIDUAL FILING PORT C�� 1��� SIGNATOR <br /> m <br /> w REPRESEf�TING ❑ 0WNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY N !!^ <br /> cc LOCAL AGENCY ❑ OTHER P H's <br /> a �J� Y <br /> ¢ ADDRESS �o`' - /° p lst 4V � 0, <br /> J _ STREET CRY STATE ZIP <br /> (N�A,(MEE �f�, '//� CONTACTPERSON PHONE <br /> co <br /> Z Q v IV(v4TW t/I Aj - ❑ UNKNOWN <br /> gLu <br /> a ADDRESS FloQ` , rkq <br /> n � <br /> CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> AiD/`R�'ESS � (�I1-"'" ,sit-11 �,J• �iT(� <br /> v J I STREET / `/ CRY COUNTY P <br /> w CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL RURAL TYPE OF BUSINESS D RETAIL FUEL STATION <br /> We k4lll-c- ❑RESIDENTIAL ❑OTHER FARM Q OTHER <br /> LOCAL AGENCY AGENCY NAME CON CT PERSON PHONE <br /> w w REGIONAL BOARD PHONE <br /> J (1) NAME QUANTITY LOST(GALLONS) <br /> m <br /> 0 0wNKNOWN <br /> u0i ❑ UNKNOWN <br /> J z <br /> D0mATE <br /> RED u y �y HOWDISCO RED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> TANK TEST F-] TANKREMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q ❑ REMOVE CONTENTS ❑ REPLACE TANK F-1CLOSETANK <br /> M M D D y y UNKNOWN <br /> HAS DISCHARG;;=ES FIRED? ❑��REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p ❑ YES DATE M M o o Y y LSI OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> rn <br /> F—] TANKLEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> El PIPING LEAK AGE YRS ©�TEEL ❑ CORROSION ❑ UNKNOWNCc / <br /> F--] OTHER UNKNOWN ❑ OTHER ❑ SPILL OTHER (�[ C <br /> w w CHECK ZONNLY <br /> aTERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON NLY <br /> Z N <br /> F7w a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢F <br /> U ti E] NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ¢ ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> 31, pFW7 <br /> t vY, a��� w� rr- <br /> w u s b e e,n r sty C <br /> h <br /> 4ib cep u n e0� <br /> o L <br />