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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OFEMERG Cy <br /> sERVICES FOR LOCAL AGENCY USE ONLY. . <br /> REPORTSEEN FILED? <br /> ❑YES NO YES O O I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASEN THE HEALTH AND SAFTY CODE <br /> M yi 1 <br /> v SIGNED <br /> NAME OFINDMDUALFILINGREPORTET PHONE SIGNATURE —Y ` <br /> w Resc,/L. <br /> 0 REPRESE G O OWNERfOPERATOR O REGIONALROARD C(+OMPANY OR AGENCY NAME [�/. �/.. <br /> n AGENCY OTHER <br /> ADDRESS <br /> /10,9 /l � SHEEF �J , C4 / <br /> �WQS <br /> SLATE <br /> NAME CONTACTPERSON PHONE zm <br /> UNKNOWN ( — <br /> N <br /> aa ADDRESS _ <br /> W <br /> 2 <br /> STREET CRV Pp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR STATE <br /> Die se enc <br /> a ADDRESS <br /> a o f o n f s�o �6r'? s r�0 b e";A/ 9.s"ao5 <br /> m rF,!4,T)/ <br /> REET TYPE OF AREA cm <br /> �./.T_- O COMMERCIAL O NDUSTRIAL O RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> e r V O RESIDENTIAL 0 OTHER O FARME::] OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> fg "540&a I It,) I4eaHk 1J' ic1" ,lace-ri e- C+o-'ulla (�o�i�6P-3 <br /> M;{I REGIONAL BOARD <br /> PHONE <br /> =Y C V R <br /> It) <br /> NAME OUANTITY LOST(GALLONS) <br /> d ie se- I �S(�LLe-1 <br /> (2) [QCNKNOWN <br /> UNKNOWN <br /> DATEDISCOVERED HOWDISOOVERED INVENTORY CONTROL O NUISANCE CONDITIONS <br /> M�7 O SUBSURFACE MONITORING <br /> M M o D Y Y O TANKTEST O TANK REMOVAL OTHER 4�-� rLis r.L its <br /> 3 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> MI u o o v y <br /> UNKNOWN REMOVE CONTENTS REPLACE TANK O CLOSE TANK <br /> HAS DI HARGE BEEN STOPPED? REPAIR TANK REPAIR PW WG CHANGE PROCEDURE <br /> p YES O NO IFYES,DATE MI M1 01 Di y OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSES) <br /> F-1 TANK LEAK O UNKNOWN GAL, FSERGLASS O OVERFILL RUPTUREFALURE <br /> 0 PIPINGLEAK AGE VRS STEEL CORROSION PEJUNKNOVM <br /> a, OTHER EeUNKNOWN OTHER <br /> SPILL O OTHEfl <br /> W IL CHECK ONE ONLY <br /> UNDETERMINED E?I/SOILONLY O GROUNDWATER O DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKO ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF(a EANUP COMPLETED OR UNNECESSARY) <br /> O NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVALA13LE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> a O CAP SITE(CD) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> O CONTAINMENT BARRIER(CB) O EXCAVATES TREAT LET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HILL O NO ACTION REQUIRED INA) O OTHER(OT) <br /> F; te. rev ,ew PeveQlec� No Cocb /'exults h been stttet <br /> -For t taa s i to a -Pte o 7-4,vi A� rem"aA Res"ll-s su b m Iffe� <br /> q/1��85 wer-e Pos:�; ,,� -.dor g77r� Gzsdl:/ea� J�:ese� l�e►^os2n � <br />