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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE ?EMERGENCY SERVI FOR LOCAL AGENCY USE ONLY <br /> ru},/ REPORTSEEN FILED 4 I HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES NO ❑YES NO REPORTED THIS INFORMATION TO LOC L OFFICIALS PURSUANT TO SECTION 251007 OF <br /> h THE HEALTH AND SAFTYCODE. /p t C/ <br /> REPORT DATE / g 1 CASE* R ^T/T �/�� �. 9 <br /> lei GL2a m <br /> M 0 Y Y <br /> SIGNED ✓ DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> > LL i M S rj/F✓e t ( - 20 GG+--- <br /> REPRESEMING ❑ OWNERIOPERATOR ❑ REG NAL ROARD COCMPF OR AGENCY NAME <br /> ¢O LOCAL AGENCY ❑ OTHER SA'/✓ �/� /�rl�fiJL {✓�Ii %' J✓��1� <br /> ADDRESS P� V BV b 9 �v�f--L(J� <br /> Y ffATE ZIP <br /> i STREET PHONE <br /> � NAME � CONTACT PE/RB�ON <br /> y� ❑ UNKNOWNp(/�1 <br /> u ADDRESS /O <br /> /d� -7 _'yTREET / /`r✓ �/� cm ���GL`/V� sr�Tf�/� BP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> /!-1 , Ax 7-7v L ( ) <br /> ADDRESS �_ - 9 sl Q <br /> 8 /6t2�t/�i � /z/l CITY 57 �f7n couNry G� P <br /> 9 RfE <br /> yCROSSSTREET TVPEOFAREAA�COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> N/�il� ❑RESIDEN IAL ❑OTHER ❑ FARM OTHER <br /> w LOCALAGENCY AGENCY NAME nJ1' CONTACT PERSON PHONE <br /> w f}N Oft I/iv JA � til) <br /> REGIONAL BOARD / PHONE <br /> G <br /> VR A, e-- U X7(7 <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> ❑ UNKNOWN <br /> e,vLe- <br /> (� <br /> - E 6 to a vT a v� ei ❑ UNKNOWN <br /> i DATE DISCOVERED '� HOW DISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACEMONITORWG ❑ NUISANCE CONDITIONS <br /> REMOVAL OTHER <br /> M D1 D !Y 1 Y ❑ TANK TEST TANK MEIHOO USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> DATE DISCHARGE BEGAN <br /> i UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK - ❑ CLOSE TANK <br /> 5� HAS DISCHARGE BEEN STOPPED? Y ❑ REPAIRTANK ❑ REPAIR PIPWG ❑ CHANGE PROCEDURE <br /> Q �ES ❑ NO IFYES,DATE D D y ❑ OTHER <br /> SOURCE OF DISCHARGE TANK/S Oy-�NL�V�CAPACITy MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> ❑ PIPINGLEAK ""��� AGE YRS STEEL ❑ CORROSION >(UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECKONEONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Z CHECKONEONLV <br /> MIZ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> RR�y ❑ NOACTKINTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0;; ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(M <br /> a4 GT) ❑ REPLACE SUPPLY(AS) <br /> �� E] CONTAINMENT BARRIER(CB) ❑ PUMP&TREAT GROUNDWATER( <br /> EXCAVATE&TREAT(ET) ❑ <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> /— � nder�ll^a�TAa S re. hfc �sueve� , f�irizfG,f,,rz s:� <br /> �SseS55;0A , w;4G ba� red u e <br /> ��e a e <br /> �/e �`� <br /> e Xeor�7�9Miv.f T/oi✓ fJ S J Y <br /> Hscmlasn <br />