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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICESl- FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED? 'I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> Q VES � Q YES NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT T SECTIO%3180.7 OF <br /> THEH L ANDS CODE <br /> REPORTD / (y, CASEi �[„/^M1 <br /> ff-w (7 O v Y SIGNED r` MTE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> REPRESENfIAL Q OWNER/OPERATOR Q REGIONALBOARD COMPANY OR AGEN NAME <br /> yy J/ <br /> LOCAGENCY OTHER IJ,. (., - <br /> a <br /> ADDRESS <br /> �-rd <br /> ATE <br /> NAME .,/ CONTACTPERSON rPHONE J / <br /> �� vC6 lAmmN <br /> u ADDRESS / <br /> O 3 y N � GL ATE �✓q <br /> J J <br /> FACILITY NAME IF APPLICABLE) OPEMTOR PHONE <br /> eoe <br /> ADDRESS <br /> y CROSSSTREET TYPEOFAREA COMMERCIAL Q INDUSTRIALE::]RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> Q RESIDENTIAL Q OTHER Q FARM OTHER <br /> . % LOCALAGENCY NCY NAME CONTACTPERSON PHONE <br /> w <br /> L er4Z l a J ! a� +ll 3Y <br /> w REGIONAL BOARD PHONE <br /> qg (1) NAME QUANTITY LOST( L.Oy3) <br /> 5 # ,Lys'/: <br /> T NOWN <br /> 9291 <br /> a �T�/ <br /> / lkUNKNOWN <br /> �- DATEDISCOVERED 770—w 2r <br /> Q INVENTORY CONTROL Q SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> O M <M 'Z.1L D B y19 1 v TANK TEST TAM(REMOVAL Q OTHER _ <br /> DATE DISCHARGE BEGAN I� METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> MI Ml o y Y LJ Q REMOVECONTENTS Q REPLACE TANK CLOSE TANK <br /> HAS DI ARGE BEEN STOPPED? +/ y Q PN <br /> REPAIRTANK Q REPAIRPG Q CHANGEPROCEDURE <br /> 5 ES Q NO DYES,DATE �M o '?.I Ov q Y Q OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> Q TANKLEAK UNKNOWN �� GAL Q FIBERGLASS Q OVERFILL Q R RE.FAILURE <br /> Q PIPINGLEAK AGE � YRS EJ STEEL Q CORROSWN UNKNOWN <br /> Q OTHER INKNOWN Q OTHER Q SPILL Q OTHER <br /> yw C14ECKONEONLY - <br /> �3 Q UNDETERMINED O�BOILONLY Q GROUNDWATER Q DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Fg CHECK ONE ONLY <br /> NT OF <br /> IN <br /> ESS <br /> IGNED <br /> PLETED OR <br /> Q SITE <br /> NOACTIONINVESTIGATION <br /> TAKEN IQOPOST CLEA(DEFINING <br /> NUP MONITORNGNRPROGRESQQ NO FUNDS AVVAILABL TOPROCEED�F(CLEANUP <br /> EVV UATING CLEANUP ALTERNATIVES <br /> f <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> o Q CAP SITE(CD) Q EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) Q ENHANCEDSIO DEGRADATION(IT) <br /> 2� Q CONTAINMENT BARRIER(OB) Q EXCAVATE B TREAT(ED Q PUMP&TREAT GROUNDWATER(GT) Q REPLACESUPPLY(RS) <br /> Q TREATMENT AT HOOKUP(HU) Q NO ACTION REQUIRED INA) Q OTHER(OTJ <br /> Z aZAZ6 <br /> q�l,(,0�-E,�� �✓.a�.f.�-C./L��.�u�- � L1E�yY+�� iw�.Ctt�C: P,�..,y[,��, <br /> Q4 i2G (J j �0�4�f 4;ei SLP AL <br />