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LTO-LX40 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI s FOR LOCALAGENCY USE 0 <br /> YES NO REPORT BEEN FILED? YES NO THEREBY CERTIFY THAT 1 AM R D I GOVERNMENT EMPLOYEE ANDTHAT't HAVE <br /> REPORTED THIS INFORMATI I ICIAIS PURSUANT 7O,SECTION M80.7 OF. <br /> REPORT DATE CASE# THE HEALTH AND SAM CODE ` <br /> �( ��+ f <br /> OM l 3 M -I y O y SIGNED DAT <br /> NAME OF INDIVIDUAL FILING REPORT PHONE ,g SIGNATURE <br /> 4� <br /> 4 344( <br /> o REPRESENTING O OWNERIOPERATOR REGIONALBOARD COMPANY OORAGENCY NAME �•,�,' �" ,,� y�` <br /> 0 �OCAL AGENCY OTHER `-ice` �6`-P� C� <br /> a <br /> wADDRESS <br /> j000 ,. <br /> STREET GTY STATE ZIP <br /> NAME <br /> (� -� CONNT�AC�TTPER�SO/N 2 PHONEco <br /> f, 2�j� <br /> m ),... I Arice! � �!'I � L � UNKNOWN �� V�I�fes- 1� r N/� )l101-I'J•` -N <br /> d ADDRESScn <br /> cr 52-1 • I rte <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> ) ��?�i �• N,�� fit" t...�N� ���eAc�.L�rJ �1�23� <br /> STREET CRY COUNTY ZIP <br /> CROSS STREET \ TYPE OF AREA 0 COMMERCIAL 0 INDUSTRIAL 1 RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> !�{VC� 12G�►� a RESIDENTIAL a OTHER FARM BOTHER <br /> LOCAL AGENCY AGENCY NAM CONTACT PERSON PHONE <br /> -fw.� ,C� u,N � e2 0 �a � v `t ' X41 <br /> z W t� u �r.-+tet t a ��1� _ ( .�.o 4t�-�- <br /> w w REGIONAL BOARD PHONE <br /> �s -vAuc-� 1�., r1kc � PLS r� (atiw <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> 2t�UNKNONM <br /> 9 Q (2) <br /> (n UNKNOWN <br /> Z <br /> DATEDISCOVERED HOW DISCOVERED E] INVENTORY CONTROL a SUBSURFACE MONITORING Ej NUISANCE CONDITIONS <br /> " M M D D Y Y [! 1 'ANKTEST a TANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN � REMOVE CONTENTS 0 REPLACE TANK [—] CLOSE TANK <br /> w M M D D V Y <br /> p HAS DISCHARGE BEEN STOPPED? (Q10'REPAIR TANK �REPAIR PIPING E::] CHANGE PROCEDURE <br /> -p �YES E] NO IF YES,DATE n M ( D °�o 8 y �" Y OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> cu�3 a TANK LEAK ZUNKNOWN <br /> Y � GAL• 0 FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> El PIPING LEAK AGE E YRS T STEEL CORROSION UNKNOWN <br /> OTHER UNKNOWN Q OTHER SPILL a OTHER <br /> W a CHECK ONE ONLY <br /> 0�-I O UNDETERMINED le�SOIL ONLY GROUNDWATER [::] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS D SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> QF <br /> U'n [::] NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Es z O CAP SITE(CO) a <br /> EXCAVATE&DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) 0 ENHANCED BIO DEGRADATION(IT) <br /> Es 0 <br /> w0 CONTAINMENT BARRIER(CB) 0 EXCAVATE 6 TREAT(ET) PUMP&TREAT GROUNDWATER(GT) 0 REPLACE SUPPLY(RS) <br /> 0 NO ACTION REQUIRED(NA) OTHER(OT) <br /> TREATMENT AT HOOKUP(HU) � O <br /> N �- (l �v�•�is Fr��l ,-�,�`�' ��P��'� �P�S�rr►��.�� �� Si�i P�2��.1c-�`� <br /> ul <br /> NSC 05(4,87) <br />