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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY U <br /> YES <br /> REPORT BEEN FILED? SE ONLY <br /> YES �NO I HEREBY CERTIFY!THAT I AM'A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORT DATE REPORTED TH18�S INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> CASE# THE HEALTH ASID SAFTY CODE; <br /> UMI SS � <br /> SM c)D D Y ' y e <br /> NAME OF INDIVIDUAL FILING REPORT DATE <br /> PHONE SIGNATURE <br /> CG�ts (2�,) <br /> wo REPRESENTING OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p <br /> LOCAL AGENCY OTHER <br /> LilH \ �� y 1` <br /> cc ADDRESS v IS?✓i c� <br /> S REEF CITU <br /> Lu NAME STATE ZIP <br /> m <br /> LLJ <br /> CONTACTPERSON PHONE <br /> zQ O� t e�� Tec , O UNKNOWN I <br /> Qa ADDRESS Ile, �✓oS S (2:) <br /> FACILITY NAME(IF APP (CABLE) CITv STATE ZIP <br /> OPERATOR PHONE <br /> O t Q�� <br /> ~ ADDRESS II�h ��oSS <br /> a <br /> 2( / S BEET �J`-� % S"� <br /> FA CROSS STREET crry �i�.. <br /> TYPE OF AREA RST cou v ZIP <br /> (( Ix I COMMERCIAL � INDUSTRIAL LRURA:LFT'PE OF BUSINESS <br /> O Q t RESIDENTIAL OTHER RETAIL FUEL STATION <br /> O FARM OTHER <br /> rn LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> w PHONE <br /> J REGe <br /> AL BOARD (\ PHONE <br /> �a �K�Vc I V II <br /> NAME QUANTITY LOST(GALLONS) <br /> w <br /> o �roL-r�� 5 E UNKNOWN <br /> y� T Nn \J <br /> 1 I v 2 v2. 1 �� ti h J NKNOWN <br /> Z DATE DISCOVERED r_ HOW DISCOVERED � INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> vM Z M '2Df 0 6 v �y TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) FFF <br /> w M M o o v y 0 UNKNOWN REMOVE CONTENTS 0 REPLACE TANK CLOSE TANK <br /> p HAS DISCHARGE BEEN STOPPED? ` REPAIR TANK El REPAIR PIPING CHANGE PROCEDURE <br /> p YES [:] NO IF YES,DATE O M � Zo 7p 6%YJ 7-Y OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSES) <br /> TANK LEAK UNKNOWN GAL. 0 FIBERGLASS OVERFILLTO RUPTURE/FAILURE <br /> PIPING LEAK AGE YRS STEEL CORROSION I xI UNKNOWN <br /> OTHER UNKNOWN OTHER SPILL u OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> v E::] UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> z� <br /> cc <br /> ww a 0 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U rn NO ACTION TAKEN [::] POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> CAP SITE(CD) El EXCAVATE&DISPOSE(ED) E:] REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> 2 CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) El <br /> PUMP&TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) [�] NO ACTION REQUIRED(NA) D OTHER(OT) <br /> y V�V�� <br /> ~ ✓.71 1 Co, �lw,�hQ,-�oh 11a�6 a`i✓„'�I. A..I� <br /> Lu <br /> z JI <br /> HSC 05(11-1) <br />