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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY NO HAS STATE OFFICE OF EMERGE SERVICES FOR LOCAL AGENCY USE ONLY .-: <br /> REPORT BEEN FILED Z I:HEREBY CERTIFY:EiA7:l:::AWA.A.DESIGNATED GOVERNMENT EMPLOYEE.AND THAlj:F VE <br /> ❑ YES YES ❑ NO FtEPOATE <br /> .....E3';THIS.INEpf�MATIONTO LOCAFOFFICfALS PURS(JANT T4 SECTION 251801 OF; <br /> REPORT DATE CASE 1 THE HEAL D �E' <br /> yj <br /> NAME OF INDIVIDUAL FILIN PORT PHONE SIGNATU <br /> m COMPANY OR AGEN NAME <br /> w REPRES ENG ❑ OWNERIOPERATOR ❑ REGIONAL80ARD <br /> LOCAL AGENCY ❑ OTHER 3� � <br /> a <br /> cc <br /> ADDRESS <br /> !�• D- a0 <br /> 0 s�TjG1 r� / <br /> STREET � CITr STATE ZIP <br /> NAl!MEmay gyp', , nom' [/�,� 905NNTACTPERSON PHONE <br /> z e GW/W U W . ❑ UNKNOWN Rob b i A/�'ee -e r <br /> a ADDRESS <br /> 4 D <br /> cc 3a D l 70 S fY'Sr, ��QiyjGI� C/q <br /> SrATS ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a r <br /> tj ADDEREE]SS �jyS' �', ?5s 0.7 <br /> J ! G�' -7 F STREET CRY GOI1NiY P <br /> yCROSS STREET TYPE OF AREA MMERCIAL❑INOUSTRIAt ❑RURALTYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> BVI�C� ❑RESIDENTIAL ❑OTHER ❑ FARM �THER <br /> LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> S- 5 D,` 6-u <br /> Lu REGIONAL BOARD /PHONE <br /> (� 2 2f 1 ? <br /> (il NAME QUANTITY LOST(GALLONS) _ <br /> U ow UZ <br /> J <br /> f21 <br /> y ❑ UNKNOWN <br /> z <br /> z DATEDISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ 5U URF AC MONITDRIlJG ❑ NUISANCECONDITIONS <br /> � � <br /> �M <br /> I ., `/D 7 p (J r !g r ❑ TANK TEST E] TANK REMOVAL OTHER J <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D p v v UNKNOWN ❑ REMOVECQNTENTS CD REPLACE TANK ❑ CLOSE TANK <br /> } HAS DISC GE BEEN STOPPED 7 ❑ REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE MI D D Sr 1 , <br /> ❑ OTHER <br /> H SOURCE OF DISCHARGE / TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ��/'j(UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> ❑ PIPING LEAK AGE YRS STE€L ❑ CORROSIONKNOWN <br /> ❑ OTHER NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W d CHECK ONE ONLY <br /> ❑ UNDETERMINED a2l SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY I <br /> y <br /> Q C ❑ SI INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> v y NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATNES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> og ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> 2$1 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) 0P&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER JOT) <br /> x a�'tvyll- <br /> ✓K/� �{.�N ���+5� �` / f.+� �i��� V i HSC.45'(STI <br />