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Now <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> TO <br /> RLOCALAGENCY.I - <br /> Q YES NO REPORT BEEN FILED 7 [::]YES O NO (NEREBY;CERT(FY;H �{ 1(;1`IA7ED GQYEEiNMEfNT:EMP[QYEEANO THAT I NAVE;: <br /> REPORTED THIS F, A ON:T OF,F(C(A1S PURSUANT 70 SECTION 2510 OF: <br /> REPORT DATE CASE aK THE HE711:TH <br /> (� <br /> vM SM � ` D �Y o Y SIGNED. �. ' <br /> ...... ............. ...... ... .. ... <br /> _. DATE:.: <br /> PHONE <br /> NAME OF INDIVIDUAL FILING REPORT SIGNATURE <br /> ✓ -- (Loi) <br /> a�Z� Gay4o <br /> REPRESENTING Q OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> t2 rgn LOCAL AGENCY a OTHER 1. �O� „t�. �O[ - ( �eGlfi�+ ��S �✓icfi <br /> Q <br /> AD6RESS <br /> 60 1 T . N4 Q. 2-- <br /> S�EET � CITY STATE 2R <br /> NAM,(E�/ CONTACTPERSON PHONE <br /> ►`o c1� �o�..S-4�v aT UNKNOWN <br /> X16 y-Ir-3�q <br /> a ADDRESS <br /> 1 3 ET �STAA1 E ' l S� P <br /> �~ STATE ZIP <br /> FACILII�TYNAME(IF APPLICABLE) OPERATOR (� PHONE <br /> ADDRESS <br /> STREET <br /> P <br /> CROSS STREET TYPE OF AREA COMMERCIAL 0 INDUSTRIAL Q RURAL TYPE OF BUSINESS <br /> RETAIL FUEL STATION <br /> a RESIDENTIAL Q OTHER Q FARM OTHER <br /> g LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> y <br /> W L �,.r, 50 Low( eaktti �s� (�, ✓;e �.lla. (Z�) kr�- 3�(2 <br /> w REGIONAL BOARD PHONE <br /> in (1) NAME QUANTITY LOST(GALLONS) <br /> wp <br /> g Q��.t'e'.- �'-, UNKNOWN <br /> 0j (2) <br /> N Z <br /> � � UNKNOWN <br /> Z DATEDISCOVERED HOWDISCOVERED INVENTORY CONTROL 0 SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Lu <br /> q 3 M ( D �D v �v TANK TEST TANK REMOVAL 0 OTHER <br /> DATE DISCHARGE BEGANYYom� METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> rrrccc <br /> w M M D D v y KI UNKNOWN REMOVECONTENTS E:] REPLACE TANK I YI CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK a REPAIR PIPING y❑� CHANGE PROCEDURE <br /> p YES O NO IF YES,DATE � 3 I IAM D �D �r ' v 0 OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK EX UNKNOWN l 0-1 aII S� GAL. Q FIBERGLASS [::] OVERFILL E:] RUPTUREIFAN.URE <br /> e a PIPING LEAK AGE YRS STEEL E:] CORROSION E�g'UNKNOWN <br /> OTHER rs:4 UNKNOWN OTHER a SPILL 0 OTHER <br /> w w CHECK ONE ONLY <br /> U a. <br /> a UNDETERMINED FV SOIL ONLY GROUNDWATER Q DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> zN <br /> cwca Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESSF--] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢� <br /> v rn a NO ACTION TAKEN POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVALABLE TO PROCEED a EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> oO 0 CAP SITE(CD) F--j EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) a ENHANCED BIO DEGRADATION(IT) <br /> F--] CONTAINMENT BARRIER(C8) r EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) Q REPLACE SUPPLY(RS) <br /> O� TREATMENT <br /> ^ AT HOOKUP(HU) O(( NO ACTION REQUIRED(NA) �( OTHER(07) <br /> H �Jy��►'Y��H.q��ol.. �o`��Cl, pv✓l�.t f� `�Q� Vt�..^OVV\. <br /> Z <br /> w <br /> 8 <br /> HSC 05(41871 <br />