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It � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES �QR LOCAI'AGEIVCY USE ONLY <br /> REPORT BEEN FILED'4 <br /> ❑ YES NO ❑Y£S ❑i°� 11iERE8Y.CfRTIFY THAT 1 AIW A,MSIMATED GOVFANMELM EMPLOYE AND THAT FFTAVE, <br /> AEPORTED E5 IN£ORMAT ;TOFFICfAf S.;PURSUANT TO SECTION 25�8t1 J O> <br /> I <br /> REPDRTOATE CASE+s THEN AN <br /> NAME OF INDIVIDUAL FLING REPORT .� . PHO SIGN ATU <br /> �cl d C As. (Zaff yr f- sq(10 <br /> � REPRESENTING ❑ OWNERIOPERATOR ,,❑ REGIONAL BOARD COM PANY OR AGENCY NAME <br /> °C LOCALAGENCY OTHER saki <br /> oc ADORESS R r� _ J�_" V`. J <br /> 1 �p. YJ O� -wLJp1 �aJ) F lTc.�C��`� `' �"T��^Fi'�� c—A <br /> NAME s"'eET �1 GRy 3fATE ZIP <br /> FONTACTPERSON i, PHONE <br /> zs l�� Vall2 owe.r5 [ UN N'OWN GIc� +� ttQr.�� (2000 <br /> R a ADDRESS <br /> Lu <br /> erry $TATE ZIP I <br /> FACILITY NAME(IF APPLICABLE) , OPERATOR PHONE <br /> TV1 V��l� �Jov a- <br /> Uq ADDRESS s .k <br /> eLl <br /> CROSS STREET TYPE OF AREA cm �y P <br /> OOMMERCtAL INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION ' <br /> +�[� R�q ❑RESIDENTIAL OTHER ❑ FARM OTHER i <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> LLI <br /> 5LLJ �.. Soq ,;.�. �.[ a I �, D, �=�# L.�.�,,;� C6ckikl� (z-9� 4q(pt z - <br /> w LLj REGIONAL BOARD PHONECL <br /> J <br /> VgiLP 9 (L ) S(01-9 t'e Cam <br /> f�) NAME QUANTITY LOST(GALLONS)LU <br /> 7 <br /> -e UNKNOWN <br /> y q <br /> t�va`G✓"•^� �vo��✓�so.►, UNKNOWN <br /> r DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �+ Zo �o v �v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN ° METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) i <br /> u u o n r v UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES ❑"ND IF YES,DATE D I Zul ZoI 3 a �y :s❑ OTHER :? <br /> y SOURCE OF DISCHARGE TANKS ONLY)CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN FIBERGLASS OVERFEL ❑ RUPTURE/FAILURE `F <br /> ❑ PIPING LEAK AGE YRS s ❑ STEEL ❑ CORROSION UNKNOWN f <br /> �y ❑ OTHER UNKNOWN OTHER LrlC+tot...rti ❑ SPILL ❑ OTHER <br /> yw w CHECK ONE ONLY 1 <br /> c3 ❑ UNDETERMINED E::] SOILONLY GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> 2 W <br /> �F SITE gVVESTIGATION IN PROGRESS(OEFINMG EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> v o NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR TAILS) <br /> 0 0 F7 CAP SITE(CD) _ ❑ EXCAVATE I.DISPOSE(ED) _ ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ 'EXCAVATE A TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> cr <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) i <br /> C VvLu <br /> `�"OltilF [/�-✓VLOV1� II <br /> 5! { <br /> 217- <br /> slk�- <br /> • NSC OS Int <br /> • I: <br />