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- G <br /> J1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FQR L,GCAL/�GENCY USE'ON4 ; <br /> ❑ YES NO. REPORT BEEN FLED? ❑YES ,=-,� 1 HEREBY GERTIF.Y THAT:)AM A pEStGNATED GOVERNMENT EMPLOYEE AND.THA7 I}{A1'E: <br /> L� ""� REPORTED THI$>(NFQRMATION.TO;LOCAL.CFICIIU S:.YURSUMiT':Tp:.SEGTION?251A07>OF <br /> REPORT DATE CASE i1 THE H 1H ANq S_AFTY <br /> �'� 407 <br /> 7 <br /> OM f M o v O r TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> Y -�7IMe I�"AVILA (20) q-b f,N co <br /> « G <br /> o REPRESENTING OWNERJOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME L <br /> o LOCAL AGENCY ❑ OTHER <br /> CL <br /> Lu <br /> cc ADDRESS <br />. <br /> ILL)U STREET r{� �/� CITY q <br /> �S�rO`- _ srATE <br /> NAME CONTTAA7CT PERSON PHONE <br /> Ln z� c-. ! _V, 1n�L ❑ UNKNOWN / G -01) <br /> �7 ?� <br /> a ADDRESS <br /> isQ ��-{n ///y'''t_u'—/[/may <br /> STREET 1 ►L CRY STATE �: <br /> FACILITY NAME(IF APPLICABLE) OPERATOR P110 hE <br /> r- <br /> q ADDRESS +/]�]�''} <br /> ul L V V STREET �J-` CVY�\;\I 1 1 l.� CRY CWNTY <br /> rn CROSS STREET TYPE OF AREA . MMERCIAL INDUSTRIAL RURAL PE OF BUSINESS <br /> ❑ ❑ ETAILFUELSTATION <br /> ❑RESIDENTIAL-❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> (24 1-31� <br /> w REGIONAL BOARD <br /> a <br /> PHONE <br /> Ula II) NAME QUANTITY LOST(GALLONS) <br /> ire l C7v�1/u0- dUNKNOWN <br /> N Unl <br /> d UNKNOWN <br /> w DATE DfSCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> kl Up �M I/p ❑ TANK TEST y TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Cc <br /> > KNOWN ❑ REMDYE CONTENTS ❑ REPLACE TANKCLOSE TANK <br /> M M o D Y Y <br /> HAS DISCHA BEEN STOPPED? ❑ "REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o' YES ❑ NO IF YES,PATE Cl OTHER <br /> �gja o 6 o I�a Y Y <br /> y SOURCE OF DISCHARGE TANKS NLY�CAPACLTY MATERIAL CAUSE{S).. <br /> ❑. TANK LEAK NKNOWN GAL. FIBERGLASS <br /> ❑ Q OVERFILL ❑ RUPTUREiFAILURE <br /> I ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION F 'UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER �/L '�L9Xh� ❑ SPILL ❑ OTHER <br /> w w CHECKONEONLY <br /> FE ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER <br /> ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLYBEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zU) <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NO ACTION TAKEN � <br /> ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED �/EVALUATINIi CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE.FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> LU <br /> ❑ CONTAINMENT BARRIER{CB) EXCAVATE&TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GI) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENTAT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑` OTHER(OT) <br /> N _ <br /> F <br /> z <br /> W <br /> HSC 05(4;) <br /> �i <br />