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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE FOR LOCAL AGENCY USE ONLY . <br /> REPORT BEEN FLED? <br /> ❑ YES NO a YES P1O 1 HEREBY CERTIFY. I;AJHAT M A,66GpvmNMENi EMFyI.OYE ANb 7HAt(NIAV <br /> REPORTED THIS INFORMATION.TO LOCAL OFFICIALS PURSUANT TO:SECTION 81807 OF.; <br /> REPORT DATE CASE# TH AND YCO <br /> v <W;, fl yD017E;', <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNA RE <br /> o REPRESE G COMPANY OR AGENCY NAME <br /> �u ❑ OWNEWOPERATOR ❑ REGIONAL BOARD <br /> LOCAL Atr GENCY ❑ OTHER l J L'/cc <br /> ADDRESS <br /> ] //�' (� L� <br /> !!!F✓I Gi �/ Q��'S7REETI •-' y t-�TE ZIP <br /> /572 <br /> NAME C TACTPERSON PHONE <br /> ( U ❑ UNKNOWNl}C /FF/ ( S <br /> IL ADDRESS <br /> S�o� �NTE7E'PRIS = C7'P—EST 'J�'-�/bON>" C R 4539 <br /> TREET erry STATEmlp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> QtZ ( <br /> ADDRESS <br /> �u STFiEEr Cm CCUNITY <br /> rn CROSS STREET TYPE OF AREA COMMERCIAL❑INDUSTRWL❑RURAL TYPE of BUSINESS RETAIL FUELSTATION <br /> w� <br /> [—]RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> y <br /> 40 <br /> REGIONAL BOARD ( ) <br /> V91 / <br /> PHONE <br /> G 1r,2W <br /> w (�) r NAME OUANTITY LOST(GALLONS) <br /> C�L EC..r UNKNOWN <br /> � ca <br /> UNKNOWN <br /> r DATE DISCOVERED HOW DISCOVERED <br /> w ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M M D 0 D y y ❑ TANK TEST ❑ TANK REMOVAL <br /> pr <br /> J�DUTj AJC 11,0�f'� MOAIJ r(p-IN <br /> DATE DISCHARGE BEGAN t.METHOD USED TO STOP DISCHARGE(CHECK ALL TWAT APPLY) <br /> W M M D D y v LrJ UNKNOWN Q REMOVE CONTENTS ❑ REPLACE TANK F--] CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED? UAlpWorlIV REPAIR TANK F-1 REPAIRPIPING ❑ CHANGE PROCEDURE <br /> p E] YES O NO IFYES,DATE M M D D v v L� "THER 1Nyc-sT4�9-TiyAJ ', L-wArN 4- <br /> SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK N?OU—NKNOWN Q W0GAL. 54-F�RGLASS ❑ OVERFILL ❑ <br /> RUPTUREiFALURE <br /> UQ El PIPING LEAK AGE__YRS ❑ STEEL ❑ CORROSION EL;,O<NOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER O SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> 3 UNDETERMINED O SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON Y <br /> V, <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> v ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS a NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> .56 ❑ CAP SITE(CD) Q EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODLICT(FP) <br /> ❑ ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> IfZr, E46X SI rte- 19SSr lyG7UT w/LLe ee- <br /> J45 DEQ vl P�� Tb r>�i�v� <br /> HSC OS 14W) <br />