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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED? <br />FOR LOCAL AGENCY USE ONLY <br />l HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />❑ YES Ee/N'O [:]YES [:j NO <br />REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />REPORT DATE CASE i <br />THE HEALTH SAFTY CODE. l <br />/ <br />®D � V <br />—� <br />SIGNED DATE <br />l M <br />NAME OFINDIVIDUAL FILING REPORT PHONE <br />SI ATURE j <br />Ko `Gv,R� ISI <br />-7 0 <br />0 <br />REPRESENT G ❑ OWNERIOPERATOR E]REGIONALBOARD <br />COMPANY OR AGENCY NA <br />r/iN <br />¢O <br />❑LOCAL AGENCY ® OTHER 78f11Vsl> D15TRlCT <br />STOCI(76N <br />a <br />¢ <br />ADDRESS�' <br />X533 .E. LINOSNy S7. <br />�TocKTor, c?V05 <br />STREET <br />CITY BfATE ZIP <br />AMEl7sA <br />CONTACT PERSON <br />SPOC4Jl^l1� I%�%X4Y-CT ❑ UNKNOWN <br />/PHONE <br />oma- / •/ C l�//P� �"'/ ! ��� <br />n <br />ADDRESS d <br />/.3�• /NOS 5'T. STOGNTON ware aP <br />BEE cm <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />z <br />5>ocK7av /try-owfc�/;r&v /fANv l7 <br />E l /1 t"� SSGG <br />Q <br />a <br />ADDRESS <br />x.533 ..�. .G! v stern Si . <br />Cfq QCn� <br />.S�I? CKT'od/ 1. Nry /r(� P <br />mCROSS <br />STREET <br />TYPE OF AREA O COMMERCIAL Q INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS O RETAIL FUEL STATION <br />(A))zsMv <br />1 ❑ RESIDENTIAL OOTHER <br />❑ FARM 5< OTHER A T <br />LOCALAGENCY AGENCY NAME <br />�/i/L <br />CONTACTPERSON <br />OL <br />PHONE <br />zo?) Y6'?-3v6'v <br />wliL <br />AOI <br />_QK�` <br />w <br />REGIONAL BOARD <br />PHONE <br />1� <br />1 <br />(1) NAME <br />QUANTITY LOST (GALLONS) <br />qq <br />UNKNOWN <br />go <br />�- <br />❑ UNKNOWN <br />DATE DISCOVERED <br />HOWWDDYLISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />i <br />Q <br />/M OM AlO o GY 7 v <br />& TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />0r UNKNOWN <br />❑ REMOVEGONTENTS E]REPLACE TANK ❑ CLOSE TANK <br />Q <br />^ ❑ CHANGE PROCEDURE <br />yy❑j� REPAIRTANK E] REPAIR PIPING <br />r?< OTHER � PI i�I/tIG <br />HAS ARGE BEEN STOPPED? <br />DI7ES <br />❑ NO IF YES. DATE M M o D r <br />Y JL✓ <br />u� <br />SOURCE OF DISCHARGE <br />TANKS ONLYiCAPACITY <br />MATERIAL <br />CAUSES) <br />❑ TANK LEAK ❑ UNKNOWN <br />GAL. <br />E] FIBERGLASS <br />O OVERFILL E]RUPTURE/FAILURE <br />PIPING LEAK <br />/T <br />AGE_ LO YRS <br />STEEL <br />❑ CORROSION Ig UNKNOWN <br />❑ OTHER <br />❑ UNKNOWN <br />❑ OTHER <br />❑ SPILL ❑ OTHER <br />CHECKONEONLY <br />ywyw <br />❑ UNDETERMINED WrISOILONLY ❑ GROUNDWATER <br />❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />r <br />¢a <br />CHECK ONE ONLY <br />SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) <br />❑ CLEANUP IN PROGRESS SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />am <br />❑ NO 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 />4z <br />❑ CAPSITE(CD) ❑ EXCAVATE& DISPOSE(ED) <br />❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />ws <br />w� <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE6 TREAT (ET) <br />PUMP& TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br />❑ ❑ <br />¢ <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED INA) <br />OTHER (O1) <br />w <br />�GG'/'�/CGe 5!?/l GtSS <br />Wr/� GP yL�tl/ 4 �le, IA4e <br />z <br />7/.e n ahwir <br />g <br />r <br />HSG05(4S7) <br />