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D-tk `? -)— <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑VES �� REPORTBEENFLED? ❑YES ,—,/ I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVeRNMENT EMPLOYEE AND THAT I HAVE <br /> LSQ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180,7 OF. <br /> REPORTOATE CASES THEN TH AND SAFT COD <br /> Imi DmiD Y VV DAT <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> s <br /> REPRESENTING ❑ OWNEROPERATOR ❑ REGONALSOARD I COMPANY OR AGENCY NAME <br /> 00 LOC ALAGENCY Ej OTHER <br /> w _ <br /> ADDRESS <br /> �. S < 6G u,h Sf sf 7 <br /> EET CRY HTATE <br /> �rE NAME � CONTACT PERSON � PHONE <br /> y ADDRESS <br /> 3 /v G'oKmt CIUb �- Ce-- �i5?Al <br /> FACILITY NAME(IF APPLICABLE) OPEMTOR PHONE <br /> c u l Zoll Yblo-40 <br /> ADDRESS <br /> 32-Do W.coun-r Ct-� S7ITYr �s?o <br /> CROSS ET <br /> Ar. <br /> i LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> pW <br /> 7 ! ( ) <br /> REGIONAL BbARD PHONE <br /> y (1) ^ NAME QUANTITY LOST(GALLONS) <br /> c ❑ UNKNOWN <br /> _ >i����� ❑ UNKNOWN <br /> W OATS DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONORIONS <br /> w /Ml-mlY�l o V ❑ TANK TEST REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN 1�I� METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M N o o r r LDG UNKNOWN �REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> Q HAS DISC GE BEEN STOPPED? ❑ REPAIRTA��/NNJKK�� REPAIRPWNG ❑ CHANGE PROCEDURE <br /> 0 YES � NO IF YES.DATE M a U -OTHER /[_(JIM <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> I ❑ TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION Eg-UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS IUVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> c� ❑ NO ACTION TAKEN ❑ PRELIM INARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �q ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING N PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTION(S) ❑ EXCAVATE L DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED Bq DEGRADATION(IT) <br /> Z �77 <br /> 7 <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(El) ❑ PUMP&TREAT GROUNDWATER(DID ❑ REPLACE SUPPLY IRS) <br /> EMS r7 CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) O TREATMENTATHOOKUP(HU) O VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> aha ✓ si0 4sssSme�z� av i// �e r�u)rp( <br /> �o-u9 2 <br />