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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE Y SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? 1 HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT i HAVE <br /> YES ❑ NO YES NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT ATE (�Xlj Q/ CASES THE EA A SA YOODE //'//� , J// /�{/j/1 I y/y <br /> M �M O D / D V y 1 y 1 f C J ��G�'x7"r l./�V ✓1 / ! Sl 'l <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPO) ��( `, P IT1�'�I� �� SIGNA `REA ` t ) <br /> w ca <br /> REPRESENTING ❑ OWNERUOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY N E ' <br /> ccr <br /> O �OCALAGENCY ❑ OTHERLQ- <br /> a <br /> ¢ ADDRESS �Q ��" C/I T,5&-201vv <br /> �. <br /> STREET CRV STATE 21P <br /> NA�MjE, . CONTACT PERSON �PHfO�NE // `] <br /> Z_ <br /> S�cc�C n J I QUI ❑ UNKNOWN (2CT`lJ 7 77 - TD ) <br /> g a ADDRESS ) ( L �1 J C �- / - /`� q 6�l,5' <br /> w V <br /> ¢ c_7 ✓C_ STREET <br /> CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> stjS>DCo r LD <br /> UaU ADDRESS _ <br /> O <br /> w ea �� `STREET CRY COUNTY ZIP <br /> a-i CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> - S� LCe�YI�— ❑RESIDENTIAL E:]OTHER 1-1FARM �ER C <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> w w REGIONAL BOARD PHONE <br /> CL s c- / <br /> (1) (' D NAME QUANTITY LOST(GALLONS) <br /> 0 W ��C/� C S a NKNOWN <br /> J <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISC ERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> ollM*��M tor DI ` D v y v TANK TEST a TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> QUNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK E::] CLOSE TANK <br /> w M M D D V V <br /> HAS DISCHARG7NO <br /> TOPPED? ��y�1 REPAIRTANK ❑C REPAIR PIPING CHANGE PROCEDURE <br /> ❑ YES IFYES,DATE M M D D Y V U -TMER 4e <br /> Lu SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> c� ❑ TANK LEAK KNOWN GAL. FIBERGLASS OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS -U J'SEL ❑ CORROSION E�UNKNOWN <br /> OTHER O UNKNOWN ❑ OTHER a SPILL O OTHER <br /> w w CHECK ON NLV <br /> a <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK 0 NLY <br /> z� <br /> w SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> ¢F <br /> U rn ❑ 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 /> 4z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(ITT <br /> 00 <br /> w <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ¢ ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> R,� - TSS T-.ecot—u"17 <br /> sQs <br /> �-2 -0 - <br /> Nscostuan <br />