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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> t EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY U5E'ONLY <br />. <br /> r7 YES NO REPORT BEEN FILED? ❑ YES j�iEREBY CERTIFY:_THAT I AM A OESIGN.ATEII GOVMN UIFNT 'EM OYES AND THAT!HAVE', <br /> ❑ DEPORTED T#1S INFORMATION TO LOCAL OFF(CfALS Pl1RSUANF T(7 SE�TfO{f 2518Q7 OF: <br /> REPORT DATE CASE a 7HE H114LT}E AND SpFfY CODE <br /> Mi 0. <br /> p� 90 �� r SIGNFA.... <br /> GATE::: <br /> 1 NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 5 ale.( 1 (921 It —3 A2 <br /> -,46� <br /> w REPRESENTING ❑ OWNERIOPERATORGIONAL90ARD COMPANYORAGENCYNAM <br /> Q -LOCALAGENCY OTHER <br /> i a <br /> ¢ ADDRESS 4/� //P I V 0 EE!• to S / K fP <br /> Lu NAME r��) ' ./{/�'� N7 �CONTACTPERSON A / i PHONE �7 <br /> U) MA I/ f^'�J UNKNOWN <br /> Lu <br /> R a ADDRESS jI/��/ ( Cly- /�l`I <br /> N 1 I! _STREET ✓ef W I`6 :J 1 CRV / 0 <br /> STATE <br /> FACILITY NAME(IF APPLICABLE) _ OPERATOR PHONE <br /> I o li m 7 <br /> I QQyy ADDRESS r+Jf 1-7 �I'�(f ■`w't!■�• <br /> J ! ! � .REST _ � CRY GPUKIT JJ 6 <br /> �-n CROSS STREET // TYPE OF AREA COMMERCIAL❑AIgUSTRIAL❑RURAL TYPE OF 9USINESS RETAIL FUEL STATION <br /> St 047a Ii ❑RESIDENTIAL OTHER ❑ FARM [::] OTHER <br /> LOCAGEjNCY SNAGD�NLN j4i NTACTPERSON PHONE <br /> PIA 1�N ! <br /> REGIONAL BOAR � � ) <br /> w <br /> RE ' <br /> 2 D /PHONE <br /> NAME �w OUANTITYLOST(GALLONS) <br /> r° Q i/(/V1/� ► \ Y,C (Z JO ❑ UNKNOWN <br /> y UNKNOWN <br /> i DATEDISCOVER�EID �`,(, HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w u M `moo o i v ❑ TANK TESTCK <br /> TANK REMOVAL OTHER S � Z <br /> F <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE{CHECK ALL THAT APPLY) <br /> Lu ml 0 o Y r ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> n ❑ YESNO 0:YES, u MI o� of v r ❑ OTHER <br /> tu SOURCE OF DISCHARGE TANKS O/NLY,CAPACITY MATERIAL CAUSE(S)'3- <br /> ❑ TANK LEAK UNKNOWN !,00 GAL. Q FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> PIPING LEAK AGE..YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> OTHER ❑ UNKNOWN OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) O <br /> F CHECK ONE ONLY [ <br /> Z N 1 <br /> ¢a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS [:] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> y y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o F-1CAP SITE(CD) ❑ EXCAVATE S DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT)Lu <br /> ❑ CONTAINMENT BARRIER(CB) F--] EXCAVATE 6 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> TREATMENTAT HOOKUP(HU) NO ACTION REQUIRED(NA) OTHER(OT) ` <br /> �, Sv.2 i'c'Sler/ts f�� l� Gam r�ktit � nli4' 7�ruM ! �/,✓d��rr� <br /> " d re -fr= 04/ <br /> / Zr A <br /> Hu05l4Bn <br /> I <br />