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u <br /> I ` <br /> ) <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE ENOFFICE OF EMERGENCY SERVICES FOR LOCAL AG Cft <br /> ! <br /> Q YES O No REPORT BEEN FILED 7 DYES <br /> 0 NO t HEREBY CE TtEO GOVERNMENT EMPLOYEE AND THAT 1 HAVE.: <br /> REPORTED SIF OFFICIALS PURSUANT TO SECTION 25180.)OF� <br /> REPORTDATE CASE# THEHEAI. D AFIjOM MZ' 0 " OVNAME OF INDIVIDUAL FILItNG REPORT PHONE SIGNAN DATE <br /> �J AJ�d C As (2D9 ) q(ht-3KV- t <br /> REPRESEMINGO OWNER/OPERATOR F-1 BOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY OTHER S' - �O .,i1.� Lo�l �e<,( IV.. 'i)-,$'yJiZ1 <br /> A RESS _ - <br /> I�ol �.� �s zn � <br /> NAME CONTACTPERSON PHONE I <br /> H� PC,C. It UNKNOWN Cra, p0. ;y (Z�� 838 —MI6 <br /> <y ADDRESS <br /> w ^ <br /> ZooOI LCT QY�r 5 EVIG Qo-);or- tf.- �cm�o� C!T q3z I <br /> STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) 1 OPERATOR PHONE <br /> z0 PoLGOost I CV- o4V,5 <br /> ADDRESS f 1 t� YL [ <br /> 20o0I ��1-12rr �./L P. .7. �x `{S8 Fs��o... Cfl CIS 32- I <br /> r <br /> MEET CITY COUNTY pp <br /> q CROSS STREET TYPE OF AREA O COMMERCIAL O PIDUSTRIAL O RURAL TYPE OF BUSINESS O RETAIL FUEL STATION } <br /> G S Q RESIDENTIAL (--]OTHER Ej FARM E] OTHER <br /> g <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> qQt-3�Z� <br /> w REGIONALSOARD - PHONE <br /> CeM4r,( <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> wp 11 <br /> UNKNOWN I <br /> 0 (2) <br /> 1 <br /> N <br /> UNKNOWN <br /> i DATE DISCOVERED ee HOWDISGOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> 0. M o O o gy y E] TANK TEST po TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M <br /> w M o o Y y UNKNOWN Q REMOVECONTENTS O REPLACETANK X CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED 9 G 1 Lj REPAIRTANK O REPAIRPIP•ING lfff---j CHANGEPROCEDURE j <br /> p VES Q NO IFYES,DATE P0M CFM Z.19' p Ify 1 y O OTHER <br /> w SOURCE OF DISCHARGE TMKS\ONLYrAPACITY MATERIAL - CAUSE(S) <br /> O TANKLEAK UNKNOWN `2/ S'`�� GAL. O FIBERGLASS O OVERFILL O RUPTURE/FAILURE <br /> PIPING LEAK AGE - VflS STEEL CORROSION UNKNOWN <br /> 0 OTHER UNKNOWN Q OTHER O SPILL O OTHER <br /> ww CHECKONEONLY ikfI` <br /> p� 0 UNDETERMINED SOILONLY O GROUNDWATER O DRINKWGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i� <br /> ca O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U`A NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATINGCLEANUPALTERNATIYES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) f <br /> �z O CAP SITE(CD) O EXCAVATE&DISPOSE(ED) a REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> 00 <br /> a O CONTAINMENT BARRIER(CB) Q EXCAVATE&TREAT(ET) Lai <br /> PUMPB TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> CO TREATMENTATHOOKUP(HU) Q NO ACTION REQUIRED INA) OTHER(OT) <br /> 2 ✓OL, � 'J.�lr� w.1h4�Oh "L J �Q�,n \aKL� ✓��n1,OJo.( <br /> w <br /> 1 <br /> Nsccslaan <br />