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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES NO REPORT BEEN FLED ? YES NO HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT .EMPLOYEE AND THAT.t HAVE REPORTED THIS INFORMATION TO LOC OFFICIALS PURSUANT TO SECTION 25180.7 OF REPORTED THE HEALTH//}} 41a REPORT DATE ECASE# 3 M 0 b -v s6NED TE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE 0 REPRESEN ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME p LOCAL AGENCY ❑ OTHER a ADDRESS STREETCITY STATE 2P NAME CONTACT PERSON PHONE ti Z ❑ UNKNOWN ��% ) 23�-OL3L Ra ¢ w w ADDRESS iRJi� cc STREET CRY STATE ZIP FACILITY NAME (IF APPLICABLE) OPERATOR PHONE Ua O ADDRESS � STREET . CRY �"� COUNTY ZIP a -i CROSS STREET TYPE OF AREA COMMERCIAL 0 INDUSTRIAL ❑ RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION ❑ RESIDENTIAL [:]OTHER ❑ FARM ❑ OTHER LOCAL AGENCY AGENCY NAME CONT'SO, PHONE wA • -�-�--' moi) w w w CL REGIONAL BOAR C c GCB --Ce_ �--rQ S /�i 1e, A c o PHONE ( ) �1 o ► y (i) NA E J QUANTITY LOST (GALLONS) UNKNOWN J U1 O z rn (2) ti ❑ UNKNOWN z DATE DISCOVERED HOW DISCO D ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E]NUISANCE CONDITIONS D M M t o Y y TANK TEST ❑ TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) M M D v v v UNKNOWN F-] REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK W F-1 1REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE HAS DISCHARGE BEEN STOPPED? o ❑ YES ❑ NO IF YES, DATE Imo✓ OTHER GJ M M DI DI v y h SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) ❑ TANK LEAK UNKNOWN 3 V GAL, FIBERGLASS OVEqFLL ❑ RUPTUREJFAILURE ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSIONJNKNOWN ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER LU w CHECK ON NLY Z UNDE RMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK 906ONLY zN 6 SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) Ir U ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) o z E-]CAPSITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) ❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE 6 TREAT (ET) ❑ PUMPS TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) ❑ TREATMENTAT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) OTHER (OT) de z_ I/ NSC 05 (447)