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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> HAS STATE OFF ICE OF EMERGENCY SERVIGE5 FORLOCALAGENCYLISEONLY <br /> EMERGENCY <br /> w; REPORT BEEN FVLED? I HEREBY GF. TIFY THAT I AM A DESSONATED GOVERNMENT EMP:UYEE AND THAT I HAVE <br /> x} YES No ❑ <br /> YES L 1 '� REPORTE T IS iNFCR TO.TO i0. LFFICWS PURSUANT TO SECTION 25113.7 OF <br /> THEEJ TH SAFT 912 <br /> CASES <br /> REPORT GATE _' � (✓ �G' f?� <br /> / SIGNED W E <br /> u1 HA uI11 Y Y <br /> PHONE SIG T RE <br /> NAME FINDVVIUUAL FI�kNG RE EL �y� <br /> m ❑ REGIONAL 6OARD CoMP OR AGENC:1...... (� )� <br /> cl flEPR£5 G ❑ OWINER'OPERATOR // f\/ �/+•{-/--, <br /> s LOCAL AGENCY ❑ OTHER rt•f S-J 4..� <br /> o C <br /> a � <br /> ADDRE1 _yrC�l <br /> � SS 2� <br /> • I aTY STATE T� <br /> s FEr RHONE <br /> NAME <br /> N 'U,& /. L "l/ ❑LNKNOWN <br /> �• Z t��j <br /> ga <br /> ADDRESS <br /> y"��Tf TIY <br /> a I � IT DPERATOR Pti01� <br /> FACLZ';Ita <br /> E IVF APPLICABLE{ �� 5'1,4- <br /> ADDRESS <br /> � <br /> o . <br /> ADDRESS F- CzcI7y <br /> �Ef CfIY � _ <br /> O SiAFE}T TYPE OFF AREA[D COMMERCIAL AVDUSTRWL❑RURAL TYPEOFBUSINESS ❑RETAIL F(yJCL�STATION- <br /> N ❑RESIDENTIAL ❑OTHER ❑FARM❑OTHEROR �!'-�' <br /> AG CYNAME CONTACTPERSCN ) P.IONE <br /> PHONE <br /> w REGIONAL BOARD <br /> OUANTSTY LOST(GALLONS) <br /> L�V� AMS <br /> FLII/.NKNOWN <br /> d� <br /> r o (2) <br /> ❑ UNKNOWN <br /> N FOIA DISCOVERED ❑ IN ORYCONT90L ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> DATE DISCOVE REO <br /> w I —1 ❑ OTHER <br /> j JJY {(J y 0 0 Y Y <br /> 7 TANK TEST TANK REMOVAL <br /> DATE DISCHARGE BEGANMETHOD USED TOS TOP DISCHArt:.E(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMDVECONTENTS ❑ REPLACE TANK �ZZLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? � ❑ AEPAVR TANK ❑ REPAIR PI*W4 ❑ CHNNGE PROCEDURE <br /> �S ❑ NO IF YES,DATE �I�j uI �oID l oI Fr Y ❑ OAR <br /> BOUNCE TAN�ISCltARGE TANKS ONLY,CAAACITY MATERIAL <br /> cAUSE(Sy <br /> ❑ K LE AK UNKNOWN �G Dh0 ,OtY7 GAL ❑ FIBERGLASS E] ILL <br /> RUPTURE�FALURE <br /> ❑ PIP,NGLEAK AGE YRS T:fL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ [_-] OTHER <br /> CHECK ONE ONLY y <br /> �x ❑ UNDETERMINED 501LONLY ❑ GROUNDWATER ❑ ORINKW6WATER•;CHECKgNLYFWATER YlELLSHAVE ACTUALLYBEEN AFFECTED) <br /> r CHECKON NLY <br /> SITEWVESTSGATIONINPROGRESS(DEFININGEXTENTOFPROBLEM) ElCLEAINWINPROGRE55❑ SK3NEDOFK(CLEANUP C.OMPI.ETEDORl1NNEC�SSARY) <br /> 4 <br /> Yuri ❑ NOACTWNTAKEN E] PGST CLEANUP MONITORING IN PROGRESS ❑ Np FUN0.5 AVA[J9LETO PROCE'eO C] EVhf.VATWG CLEANLA AL7ERNATtVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) ENHANCEDDIO DEGRADATION 117) <br /> z F-1C>�SVTEICO) ❑ EXCAVATE6OLSPGSE(EOy ❑ REAIOYE FREE PflODIJCT[FP) ❑ <br /> 8 <br /> 4F— CONTAINMENT BARRIER(CB) _❑ EXCAVATE&TREAT(0) ❑ PUMP6TAEATGROUNDWATER(OT) E] REPLACE SUPPLY{RSI <br /> ❑ TREATMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(01) - <br /> 2 <br /> W <br /> 3 <br /> numt.rorl <br />