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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> 7YESGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> La'�Np REPORT BEEN FILED 7 YESNO 'I HERESY CERTIFY THAT I AM A-DESIGNATED GOVERNMENT EMPLOYEE AND'THAT 1 HAVE <br /> ❑ <br /> :REPORTED THIS INFORMATION TO,LOCAL OFFICIALS PURSUANT JO,SECTION 25160:7 OF <br /> REPORT DATE CASE THE HEALTH AND SAF7Y CODE <br /> �" a G r r Sk3NED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE ii SIGNATURE <br /> REPRESENTING ❑i OWNERIOPERATQR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 LOCAL AGENCY ❑ OTHER <br /> � ADDRESS �t <br /> E QTY STATE IP <br /> LH /N�gME i r' CDNNTACTPERSON PHONE <br /> wgo <br /> ¢ 1\UL`Jt 1�,.. W 3=1 cl•o. ❑ UNKNOWN �)Yt'Vt, LV!. L -� 240� 5:t-1 oc,l U <br /> a /ADDRESS + <br /> lJ�tr ciTi > r <br /> � . {.,fix!��. <br /> aTATE <br /> FACILITY NAME IF APPLICABLE) 7_1 <br /> PERATOR PHONE <br /> L bq);:L-' C' • 0c:.i <br /> ` ADDRESS <br /> `5�� }00 _��r�AC�T ►-:: CLET�1EiT.= r� <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL DUSTRIAL ❑RURAL TYPE OF BUSINESS r❑ RETAIL FUEL STATION <br /> C � �e / ❑ <br /> RESIDENTIAL OTHER [DFARMOTHER LT-" <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> REGIONAL BOARD PHONE <br /> N <br /> y {t} NAME QUANTITY LOST(GALLONS) <br /> ❑✓-UNKNOWN <br /> ❑ UNKNOWN <br /> ? DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 4 M a o y y ❑ TANK TEST ✓❑-TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M u y y ©'UNKNOWNREMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING "CHANGE PROCEDURE <br /> p YES ❑ NO IFYES.DATE M a o i" r y y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLY�CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK ❑ UNKNOWN 6,oC a GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> ❑ PIPING LEAK AGE YRS FeSTEEL ❑ CORROSION l UNKNOWN <br /> ❑ OTHER NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w ig CHECK ONE ONLY <br /> ❑ UNDETERMINED d SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z <br /> cc <br /> SITE MVVESTIGATM3N IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> .❑ NO ACTION TAKEN -❑ POST CLEANUP MONITORING IN PROGRESS_ ❑, NO FUNDS AVAM.ABLE TO PROCEED----❑ EVALUATING CLEANUP ALTERNATIVES- <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(Fp) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE a TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(OT) ❑ REPLACE SUPPLY(RS) <br /> • ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> MSC o5(4AM <br />