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r., <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES REPORT BEEN FLED? YES ❑ NO ,I HEREBY CERTIFY THAT IAM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ':REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORT DATE CASES THEHEALTHAN05�p/�j�f I <br /> O v Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE h <br /> e ro/ Oc-- (am) 11 3v6Nt ,e <br /> REPRESE G COMPANY OR AGENCY NAME G <br /> ❑ OWNEiVOPERATOR ❑ REGIONAL BOAS <br /> AGENCY ❑ OTHER <br /> ° rc !r sln N//cis <br /> ADDRESS / 7P /J�✓ /� - L /_ /� (—'`' <br /> 6 O e l�G�STa€ET��/� //V• STV(�- /7 {.�E ATE <br /> w NAME CONTACT PERSON PHONE 7 0(Yo iQ ❑ UNKNOWN OA'7 SCO ) 6�-o�YO <br /> S a ADDRESS _. <br /> w ,� Pmonf $fp c,Ns{on 95305 Q <br /> ¢ aY m <br /> pm <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE �J <br /> T c f ) <br /> 4 <br /> ADDRESS �'foac'Lon .-iwJoRtpwiro 9SdUs ` <br /> CITY mlM �I <br /> 55 CROSSSTREET TYPEOFAREA COMMERCLAL❑INDUSTRIAL ❑RURAL TYPEOFBUSINESS O RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM �07HER YL( <br /> LOCALAGENCY AGENCY NAME OONTACTPERSON PHONE <br /> 6W c ,SEtNOaml OZ l ) 3Vbf- 0 <br /> REGIONAL BOARD PHONE (ip <br /> m (1) NAME WIWTfTV LOST(OgLLON$)_ <br /> c! V Ine{u/s V ^L1ij-U/KKNDWN _'r <br /> (a <br /> '� ❑ UNMOWN p <br /> W DATE DISCOVERED HOW DISCOVERED ❑ JWENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONXTmS <br /> DM 6M /C 3C �r 9r E] TANCTEST TAN(REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wM D D Y Y UNKNOWN ❑ REMOVEOONTENTS ❑ REPLACE TANK O CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 E' :�] RRETp�AFIR TANK ❑ REPAIRPWNG ❑ CHANGE PROCEDURE •\ <br /> p ❑ YES ❑ NO FYES.DATE u M o o v v �� -"'-R <br /> SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> ❑ PIPING LEAK UNKNOWN ACBE I GAL.YRS ❑ FIBEERGLASS OVERFILL❑ CORROSION ❑ UNKNOWN RUPPJWFALURE A� <br /> ❑ OTHER ❑ UNKNOWN ILF❑�I�JOTTHER ❑ SPILL ❑ OTHER <br /> �Jw CHECK ONE ONLY - Aa <br /> {3F ❑ UNDETERMINED Boll-ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> H CHECKONEONLY �F <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SINNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 'AE�<O ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> a F-1CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) E] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) n PTJMPB TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> ❑ TREATMENTAT HOOKUP`r U) ❑ NOACTIN REQUIRED(NA) ^LJj/GER(OT) __�LC.Q� <br /> 0�0%/ Confamrna/!/<� ?r�{red `y /Rd <br /> �tvl ai �ssrsss��e n@tess j G Gw�iKr 44.'/bue"y- erve Fd)' <br /> 25 �e .4y <br /> a-s ulA;-d 6 k Hris+y lL ASA71 4 tRc�y <br /> p_ <br /> UI(p <br />