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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY 1. R <br /> O YES �1 /NO REPORT BEEN FILED? OYES �0 1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT.TO SECTION 2SIS07 OF: <br /> REPORT DATE CASE# THE HEALTH AND SAFTY CODE, <br /> [!T I jn^I kL—o,.-. u3 Cr.y — (-2O•r6'c) <br /> M o r v SGN DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> LA)0. A,-r- 12091 Nla`d 3L1 w 1 J <br /> REPRE E��NTING O OWNEWOPERATOR O REGIONALBOARD COMPANY OR AGENCY NAME 'I,, / <br /> Ll LOCAL AGENCY O OTHER ��a uTn LOca( 1Jca(ti'I DI st7iC+ <br /> a <br /> ADDRESS '{tel 1 /J��/�/ 1(/'j �`/'{�[ U//�' <br /> V4 W STREET �� CITU 1.. IM I $TATE `C~- 2w • /v <br /> NAME CONTACTPERSONnn PHONE <br /> �-e-Y1 O UNKNOWN 5�.r��(L ( 133 1 to <br /> a ADDRESS �^ ,/T / }+� ,� 1//�y Lod <br /> 3�( STREET / I 1 /V ✓v {ti .,TY T+O N I STATE \� P • �� <br /> FACILI NAME(IF APPLICABLE) OPE ATOR PHONE <br /> u - - r— 7i�[ SoY, Ger rem (ZtA) 33�f�ilo <br /> i ADDDRR\ES1/S�) / '}(-���(/"1/(I� �(�T �J( <br /> 5 v STREETLID 1. IV 1 V` Cm I COVMF'��1 JO UI J / o <br /> y CROSS STREET , TYPE OF AREA COMMERCIAL O INDUSTRIAL O RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> n k n 6 v ►� =RESIDENTIAL O OTHER 0 FARM Q DER <br /> g LOCALAGENCV AG CY NAME CONTACT PERSON PHONE <br /> w San�0 u��Lacal e is �f rlln knol 12U�1y(P563�{2D <br /> REGIONAL BOARD PHONE <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> S" vL 1 I/IL � UNKNOWN <br /> (2) <br /> UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> 0-1 I M D r O TANK TESTANK REMOVAL O OTHER <br /> 1 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o v y UNKNOWN O REMOVECONTENTS O REPLACETANK O CLOSE TANK <br /> QMH HAS DISCHARGE BEEN STOPPED? O REPAIRTANK �J �O/� REEPPAIRPPING CHANGE PROCEDURE <br /> p VES O NO IF VES,DATE M ( M C �ER RP MO✓� Tc <br /> u� SOURCE OF DISCHARGE TANKS ONL�V/CA/PAACIIT7Y� MATERIAL CAUSE(S) <br /> O TANKLEAK UNKNOWN 1 lJ 1 W V GAL. O FIBERGLASS O OVERFILL O RUPTURE/FAILURE <br /> O PIPINGLEAK AGE YRS STEEL O CORROSIONNNNOWN <br /> O OTHEflNKNOWN O OTHER O SPILL O OTHER <br /> w CHECKONEONLY <br /> O UNDETERMINED SOILONLY O GROUNDWATER O DRINKINGWATER. (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ¢< n SJVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uy NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 8z O <br /> 00 CAPSITE(CO) O EXCAVATE d DISPOSE(ED) O REMOVE FREE PRODUCT(FPI ❑ ENHANCED BIO DEGRADATION(IT) <br /> 0 CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) O PUMP TREAT GROUNDWATER(GT) O REPLACESUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED INA) OTHER(OT, <br /> Observed SQl I eon+a.v , rLc�fi'or, cLA f�rnx of7 LtGSr rC m01/ ho(u�✓ter <br /> w soil rest (4s no+ rece(ucC( Lkn-h' I tjIDI�9 . FiA-1Lkkf- 5i+e_ aSsess rpu L4— <br /> Lti�?C( 4V de-f t4MI'ne +kk (I GL{uie C",-d o-r, <br /> 2S , I,�-h&A rvauried 41v " pi-u� r _ ul ae <br /> KSCO51 <br />