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NOV 1 6 1°r9 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZE IRI /� dMINATION SITE REPORT <br /> EMERGENCY ! HAS STATE OFFICE OF EMERGE SERVICES FOR LOCALAGENCY USE ONLY <br /> Ej YES NO REPORT BEEN FILED 7 VES ❑ NO RE11HPORTED THIS Nr'CRMATION TOs[ACALTOFFIC1AI,S':PURSUAM�OE ECTION 251 Q7AOF. <br /> TNEHEALTH ANO SAFTY OooE j <br /> REPORT GATE r / CASE• 1' t S <br /> M M 1'� r�o v MNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT ' PHON r _ E IGNATUR <br /> r <br /> S E <br /> r I <br /> a REPRESE"G ❑ OWNER/OPERAToFI REGIONAL BOARD OOMPANY OR AGENCY NAME / <br /> c <br /> COGAL AGENCY Q OTHEfl4' <br /> O <br />�. w ADDRESS <br /> CITv VATE EN I � <br /> CONTACT PERSON <br />{ � NAME PHONE � <br /> ADDRESS f.. <br /> u 1 ) <br /> `"REET .~ cm ffiATE nP <br /> _ FACILITY NAME(IF APPLICABLE) .-- - - — OPERATOR <br /> '- <br /> ADDRESSl / L <br /> / - .. <br /> a <br /> 9mEET CRY HJUMiY ap . <br /> r w CROSSSTREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL ORURAL TYPE OF BUSINESS^ ❑ RETAIL FUEL STATION <br /> ,/ / °•��.�.«C_.. ' ❑RESIDENTIAL ❑OTHER. ❑ FARM OTHER (.•;..I. �.: 1 '� <br /> LOCAL AGENCY AGENCYNAME CONTACT PERSON PHONE , <br /> � 1 <br /> REGIONAL v ARD . /� ! I, PHONE 1 <br /> NAME OUANTRV LOST(GALLON j <br /> 1 <br /> w <br /> UNKNOWN <br /> 4 _ . ❑ UNKNOWN <br /> a DATE DISCOVER`0 y� yj- HOW DISCOVERED - ❑ I NTORV CONTROL ❑ SUBSURFACE MONITORPIG ❑ NUISANCE CONDITIONS <br /> t. �M M D D v I v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> I. DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M uUNKNOWN - ❑ REMOVECONTEI❑NTS ❑ REPLACETANK CLOSE TANK <br /> o o <br /> HAS DISC GE BEEN STI Yv J r /' ❑ REPAIRTANK O REPAIRPIPING ❑ CHANGE PROCEDURE <br /> NO FYES.DATE /M +'u o /uh Y t' ♦ [:jOTHER -{I <br /> I SOURCE OF DISCHARGE TANKS.OccyNLVr���C'''A�PACIITTY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN - // ' GAL. ❑ FIB LASS ❑ OVERFILL ❑ RUP REXAILURE <br /> O PIPINGLEAK - AGE�YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER _ O UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> I 'f <br /> w w CHECK ONE ONLY II <br /> O UNDETERMINED SOIL ONLY O GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> H CHECK ON jONLV <br /> z y �/ <br /> ITE <br /> 4 by ❑ OACT ON TAKEN NIOOPOST CLEARESS NUP MONITORING IN PROGRESINING EXTENT OF PROBLEMS =D NO FULE LIPC AN NDSAVAILABLEAIILAB N P aPRI DOFFO EVALUNUP ROMPLETED OR TING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> a 9 ❑ CAP SITE(CD) - O EXCAVATE 6 DISPOSE(ED) E:] ❑ <br /> REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> c� O CONTAINMENT BARRIER ICE). ❑ EXCAVATE A TREAT(ET) ❑ PUMPA TREAT GROUNDWATER(GI) a REPLACE SUPPLY(FIS) L.I. <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NOACTK)NREOUIFIED(NA) ❑ OTHER(OT) <br /> �Yj)S(f lil ,:J,1 (f !!-(/Y'L !F•(/.r� L./ ! 'I:fL" -LC. � ''1 r-�', 'r f 'µr , , <br /> llttF <br /> 'w.�.. .I tA <br /> 1� �. .1 f.Y: / /"�'`V.A a:.l� / / /f� r 7 �Q r .-�..�/ i✓� ��d <br /> R9cm141n1 <br />