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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY:USEDNLY <br /> ❑YES REPORT BEEN FILED 9 [::]YES NO 1 HERESY CERTfFY THAI IAM A.OESIGNATELI GOV tJ11Plf:f;E IpL,OYEE 1 D 7HAX <br /> REPORT�a T EIS,INFORi�IAT)ON TO LOCAL CfFVA(S URSIJAK TQ:SEGfIQN,25 8iF7,nF; <br /> REPORT DATE cASEa 7HEH THAIE[35/4Y ;: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN <br /> REPRESENTING O OWNER(OPERATOR ❑ REGIONAL BOARD <br /> COMPAN`YORAGENCYNAME C / _ !1 <br /> a0 LOCAL AGENCY ❑ OTHER �j -7 y + ( I GX U 1/► / "'�V Q a I <br /> ADDREIS <br /> ICJ STREET CrTv STATE ZIP <br /> NAME _ CONTACTPERSON PHONE <br /> z <br /> L � ❑UNKNOWN t ) T`1 T+tr/5 <br /> aQ ADDRESS <br /> :., <br /> Lu a <br /> )oSMUT ;Fry STArE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE ), <br /> fir c�� y-z :: 5 <br /> a ADDRESS <br /> �toSaD <br /> STREET CTTY COUNTY ap <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPEpF9USINESS ❑ RETAIL FUEL STATION � <br /> O /L�w ! <br /> ..RESIDENTIAL OTHER ❑ FARM ❑ BTHER <br /> b <br /> LOCALAGENCY AGENCYNAME CON,TAJPERSON PHONE I <br /> _3 qZD <br /> g REGIONAL BOARD PHONE <br /> L <br /> (1) NAME OUANTRY LOST(GALLONS) <br /> Lu <br /> J ! UNKNOWN <br /> fso <br /> UNKNOWN, <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORNG ❑ NUISANCE CONDITIONS <br /> u' <br /> 0.12.11 .1q 1:1TANK TEST 0 TANK REMOVAL OTHER 4 L <br /> o r v • • <br /> METHOD USED TO STOP DISCHARGE HECK ALL THAT APPLY) <br /> DATE DISCHARGE BEGAN (C <br /> UNKNOWN ❑ REMOVECONTENTS 0 .REPLACETANK CLOSE TANK <br /> w M <br /> ml <br /> a n o v r <br /> "c 7` <br /> WAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p <br /> OTHER FYES.DATC" Oj// - -�ES Ll ML0.19.'1GL-Ly <br /> %�•''- <br /> ur SOURCE OF DISCHARGE TANKS ONLYr.APACITY MATERIA• CAUSE(S) f�1 <br /> ❑ TANK LEAK UNKNOWN GAL 'FIBERGLASS ❑ OVERFILL ❑ RUPTURFFAQURE : <br /> ❑ d <br /> PIPINGLEAK AGE YRS BTEEL ❑ CORROSION UNKNOWN d l e 4; <br /> ❑ OTHER UNKNOWN ❑ OTHER SPILL ❑ OTHERrEy�? <br /> ;L'c <br /> CHECKONEONLY br <br /> ❑ UNDETERMINEDLg <br /> SOIL ONLY E::] GROUNDWATER ❑ DRINKING WATER- {CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) .6"!f <br /> CHECKONEONLY03 <br /> a ❑ SITE AVVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY). <br /> s7i 01 ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVARABLE TO TO ❑ EVALUATING CLEANUP ALTERNATNES' <br /> CHECK APPROPRIATE ACT)ON(S)(SEE BACK FOR DETAILS) <br /> z F-1 CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(IT}:o. <br /> ❑ CONTAINMENT BARRIER(CB) E-1EXCAVATE&TREAT(ET) <br /> ❑ PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY{RS) :L <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OT) <br /> w i 1 . re y ut,-e e - w X17 ft <br /> �r7V �� L/{,,.. % . 5 .I ` .. •1a3=f 4'�Lt` + L <br />