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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGE SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑�S r-�� REPOgTBEEN FLLED7 I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> !lIJJJ ES ❑ NO REPORTED THIS INFORMATION.TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT/`D�'ATE (1 (X1� �/J1 CASES THE,HEALTH A DS YCODE <br /> OM Lim l I p V T / Y _ACl�E�y GC's Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE Ni6-4 <br /> D DATE <br /> / �� ^ OSIGNATURET J ' <br /> REPRESENTING O OWNEWOPERATOR O REGbNAL BOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY ❑ OTHER c,„ _ to �G 7G <br /> ADDRESS cJG(IYL �. /�-� TYrr <br /> ��, o, Q.vx ao0 CR 95�o <br /> E <br /> �,.�^ 'I (`�ME BATE (ALL [/� <br /> ®� S'FOGK `A+' ` WlM'J'«f� UNKNOWN CONTACT PERSON <br /> PHONE 9 T T - 7L <br /> n Ip <br /> a rrrr�n el^ 79 , <br /> R 3 A E 1 p�nc�-2 :S}o�lCfv,ti. CR �15a6$ <br /> Y NAME(IF APPLICABLE) cl v BTATE &p <br /> I ,/ lU 141'1 � OPERATOR PHONE <br /> S ���---///"'111...000 ( ) <br /> 0 N , Ger rucee_ SfoUCS .�,+� 9sa s <br /> TREET TYPE OF AREq cmc, <br /> O COMMERCWL Q INDUSTRIAL Q RURAL TYPE OF BUSINESS <br /> ❑ RETAIL FUEL STATION <br /> RESIDENTIAL []OTHER O FARM OTHER Scltio-r}� <br /> GENCY AGENCY ME <br /> .}- /� CCON�TACT PERSON <br /> ir(. UOQ- � PHONE <br /> wL BOARD 1 ) <br /> u Y C 'F� L'1 r R PHONE <br /> wstel/ l.� NAMEOUANTRVLOST(OALLONS) <br /> OUNKNOWN <br /> VERED HOW DISCO RED UNKNOWN <br /> D (y ❑ INVENTORY CONTROL ❑ SUBSURFACEMONRORNG ❑ NISANCEOON)ITIONS <br /> p p vTANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> RGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> p p Y Y I-I A WN ❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> RGE BEEN STOPPED 7 REPAIRTANK ❑ REPAIR PPWG CHANGE PROCEDURE <br /> ❑ NO IF VES.DATE ©M :3 a 9Y VOT,ER 4 Iq N H <br /> uyi SOURCE OF DISCHARGE TANKS ONLYrAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK NOWN 5700 GAL, O FIBERGLASS Q OVERFILL O RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS �EL ❑ CORROSION 52-lUNKNOWN <br /> ❑ OTHER O UNKNOWN ❑ OTHER O SPILL ❑ OTHER <br /> wlu CHECKONEONLY <br /> UNDETERMINED O SOILONLY ❑ GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> N <br /> e i SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �N ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED O EVALUATINGCLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 ❑ CAP SITE(CD) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) O NOACTIONREOUIRED(NA) O OTHER(On <br /> T( t Soo a,( re q aSo / ; A.(, -F Ir o jore -S tM e <br /> a j 8 19 tet, ,�L 7'h w a sse u.ry�� .c <br />