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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> ❑ YES NO EfS ❑ NO j HEREBNCERTIFYTHAT 1 A DESIGNATED GOVERNMENT'EMPLOYEE AN THAT:,rHAVE <br /> 4ir�� R D THIS INFORMATION j0 E.00AL OFF(C(AI S PURSUANT TO SECT N 18Q 7 VE <br /> R/E,PORT DATE CASE#< 7HE H ANO CODE f <br /> !/M� (/ y y s <br /> SIG D DATE. <br /> NAME OF INDIVIDUAL FILL REER PHONE SIGNATURE <br /> acv► . V7) 1-3g2A <br /> o REPRESENTINGCOMPANY OR AGENCY NAME <br /> F ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br /> a¢ LOCAL AGENCY ❑ OTHER <br /> ¢ <br /> ADDRESS �j <br /> [l 1E�x [�oell STREET <br /> CITY STATE <br /> NAME nD J CONTACTPERSON PHONE 21P <br /> ZCC L[�(. <br /> UNKNOWN S O"1 - ) 3-+Cq' <br /> ¢ � L0 V I <br /> R Qa ADDRESS <br /> 2-v6 -s20 <br /> R STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDR6( <br /> PW? ) <br /> y CR S STREET E TYPE OF AREA <br /> COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS v <br /> L� � ) RETAIL FUEL STATION <br /> A ❑RESIDENTIAL OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME_ c� CONTACT PERSON PHONE <br /> w y! S �! •L• Ste, ttcvt,c.e �J (Zl ) <br /> w w REGIONAL BOARD <br /> CL a PHONE <br /> U w C �� QUANTITY LOST(GALLONS) <br /> �> <br /> J <br /> m Z (2) NKNOWN <br /> 41 <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MON TORING NUISANCE CONDITIONS <br /> w /� .� <br /> w �"M M o o y (�y ❑ TANK TEST ❑ TANK REMOVAL OTHER } -�-` <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M O O V y <br /> Y KNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> M <br /> op HAS DISCHAR E BEEN STOPPED? / Q) ❑ REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br /> ' ES ❑ NO IFYES,DATE dM ! yl ty ❑ OTHER T� ❑ <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL <br /> ❑ TANK LEAK UNKNOWN 3S"dCAUSES) <br /> GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ¢ ❑ PIPING LEAK AGE YRS O-STEEL ❑ CORgOSIONNKNOWN <br /> ❑ OTHER ©UNKNOWN O OTHER a SPILL ❑ OTHER <br /> LU w CHECK ONE ONLY <br /> a <br /> v UNDETERMINED a SOIL ONLY a GROUNDWATER a DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Q< a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) Q CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> F- <br /> Q`� ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED VALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 880 z ❑ CAP SITE(CO) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ui <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> cc /'❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> w <br /> 4U /�-L s �` �/ c.�a /t/ d t•,' a.� <br /> MSC OS(6R7) <br />