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B <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)!CONTAMINATION SITE REPORT <br /> EU-EnGENCY HAS STATE OFFICE OF EMERGENCY-RV^1..ES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FRED T I HEREBY CERTIFY THAT F AM A GESIGNATEO GOVERNMENT EMPLOYEE AND THAT l HAVE <br /> YES :NO �, (�ves [] REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> t - �rTHE HEALTH AND SAFTY CODE <br /> RE PORT DATE •� 77 tCASEY <br /> . 'SGNED '. WTE <br /> NAME OF 11:01VIDUAL FILING REPORT PHONE SIGNATURE _ <br /> m <br /> a REPRESENTING © OWNER'OPERATOR ❑ REGIONALBOAAD COMPANY ORAGENCY NAME <br /> n ❑ LCCALAGENCY ❑ OTHER <br /> Q ADDRESS CA 9�,:40 <br /> rJlily r...�C ..ac ur:.,;rti lSr.i:uC <br /> STATE <br /> sine Ff C:7Y 2N <br /> CONTACT PC RSON PHONE <br /> NAME i.11(}!1)S C. CU. .AVin. T.Ar,RALti) rr rl9i 35 1-(llJir <br /> ❑UNKNOWN 5.•. y <br /> a ADDA85S-. <br /> cc sTaEET <br /> CRY STATE 71P <br /> F APPLICABLEI OPERATOR PHONE <br /> FACILITY NAME(IF <br /> ..,.,.,....1:. it1J i.:. a'r.n.:i L:.r.u1M. l,. c}+ivJ I.,a•. ! .:{i'� i JJ' >jJ: <br /> ADDRESS. <br /> r raE>✓r nr HTY <br /> US CROSSSTREET <br /> TYPE OF AREA❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPEOFBUSINESS F]RETAIL FUEL STATION <br /> ....:.r-v L L i,: k.h•: ❑RESICENTIAL ❑OTHER ❑FARM❑OTHER '.iUa C t'j <br /> LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> -j1lq l rG+.� -344 L <br /> wey 2 <br /> PHONE <br /> REGIONALBOARD <br /> {l) NAME QUANTffY LOST;GALLONS) <br /> �S .J. <etlea ttjSc'+t LUu;r., ❑ UNKNOWN <br /> L <br /> ( ❑ UNKNOWN <br /> CATECISCOVERED HOWOISCOVERED ❑ INVENTORYCONTROL E] SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> U .L b b 7 ❑ TANKTEST ❑ TAM REMOVAL ❑ OTHER <br /> �u u <br /> ml o o Y Y <br /> DATE DISC14ARGE SEGAN mETHOD USED To STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> uI u oL Y� _rI ❑ UNKNOWN 0 REMOVE CONTENTS ❑ REPLACETANK E] CLOSE TANK <br /> a <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPING © CHANGEPROCEDURE <br /> (".j O I.L i1 I U rI I Y EDOTHER❑ YES ❑ NO IFYES.DATE M a o - <br /> SOVACEOFDISCHARGE TANKS ONLYnAPACITY MATERIAL CAUSE(S) <br /> �,,ol-;o ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURUALURE <br /> TANKLEAH ❑ UNKNOWN GAL. <br /> ❑ PIPING LEAK - - AGE YRS ❑ STEEL El STEEL UNKNOWN <br /> ❑ OTHER ElUNKNOWN ❑ OTHER C SPILL ❑ OTHER <br /> CHECKONEONLY <br /> F] UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKLNGWATER-(CHECK ONLY IF WATERWELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECKONEONLY <br /> siT£BJVESTIGATIONINPROGRESS(DEFINWGEXTCNTDFPROBLEM) ❑ CLEANUP IN PROGRESS <br /> ❑ SIGNEDOFF{CLEANUP CDMPLETEDORUNNECESSARY) <br /> �� ❑ NOACTK)NTAHEN [D P0.STCLEANLIPMONITORWGINPROGRE55 ❑ NOFUNDSAVAWLETOPF;OCEED E:] EVALUATINGCLEANUPALTT:RNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE{CD) ❑ EXCAVATE&DISPOSE(EO) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ OONTAINMENTBARAIER(CBy ❑ EXCAVATEbTREAT{ET) ❑ PUMP a TREAT GROUNDWATER COT) ❑ REPLACESUPPLY(as) <br /> ❑ <br /> TREATMENT ATHOoKUP{FN) ❑ NOACTION REQUIRED(NA) ❑ OTHER(OT) <br /> HSCOSI"T1 <br /> i <br />