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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI S FOR LOCAL AGENCY USE 0 ❑ YES ,KNO REPORT BEEN FILED 7 ❑ YES NO L HEREBY C FY T T t a o 1GNATEO OVERNMENT EMPLOYEE AND THAT I HAVE REPORTED ION T ICIALS PURSUANT TO SECTION 251801 OF REPORT DATE (' CASE A TH�EALTH AN S D M S M 0 D `I D �vd V SIGNED `?r DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE m REPRESENTING ❑ OWNEWOPERATOR O REGIONAL BOARD CO PANY OR AGENCY NAME I ' 0 LOCAL AGENCY [:] OTHER ti �o�, -,L.. Lo }2c'� D ✓i ct ¢ ADDRESS II n 4REET 5CITY�� STATE� 9rP�l w NAME CONTACTPERSON PHONE co J ` 11 I i Curs I � Ave"J- o E:] UNKNOWN �f I o.%/o.v� ( Z�+)9 yZ -2094 R a ADDRESS w Lu �A �r53 �6 ¢ I I STREET 7TTy STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATO/R� I II PHONE o CQr �f a✓o.✓� (tea✓+\ Na�/q.o Ua ADDRESS ,/ o ) 2—`i I 'rteSTREET �✓q c �c.� LINTY CffY COUNTY ZIP y CROSS STREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION rS �v�t ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER LOCAL AGENCY AGE CY NAME CONTACT PERSON v7 � _ PHONE w o� Joe. .r,. �oc� \ �l�(-, ��s� L4w� ��`�. ( 2eR) 4(Gk-3g24 W w REGIONAL BOARD PHONE a e��✓e I V m (�) NAME QUANTITY LOST(GALLONS) 0 L UNKNOWN (2) UNKNOWN W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS I M 1 M ` D D v �y ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) w M M D DI Yl Yl UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK fVr CLOSE TANK HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE o YES ❑ NO IF YES,DATE IMI ' M 'D "I DI �v (0y, ❑ OTHER rw SOURCE OFDISCHARGE TANKSONLY/CAPACITY MATERIAL CAUSE(S) F-] }�TANK LEAK X UNKNOWN 2�� GAL. E:] FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE 2 F-1PIPINGLEAK 7�" AGE YRS STEELE::] CORROSION UNKNOWN ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER Lu w CHECK ONE ONLY Q D- UNDETERMINED SOIL ONLY GROUNDWATER ❑ � ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY zm ¢a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) Er U rn ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) 4z F--] CAP SITE(CO) EXCAVATE&DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) 00 QF-] CONTAINMENTBARRIER(CB) EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION jREQUIRED(NA) ❑ OTHER(OT) ZSo:� ,{ ,w"Wo.��JL. hid 4vv, -t�.,1L ✓'�✓�-�Va.c , SO; I sA. +-�� ow I Kto�.- ( �vo�.H\��y.Aelr-� / U 1y�/1.�Taw�..tn.y'I+Q L- \r`'O✓ 1✓0 6-5- HSC 05(4/87)