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VAvv[nunuUNU 5I VFiAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE EMERGENCYSERV " FQR LOCAL AGENCY USE ONLY <br />REPORT BEEN FLED 7 <br />Q YES NO <br />a YES NO I HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />REPORTDATE CASE* THE HEAL <br />ND SAFTY E <br />M M (Jv v Q <br />NAME DIVIIIIIIIIDUAL FLING REPORT PHONETE <br />SIGNATURE <br />REPRES NG O OWNEWOPERATOR O REGIONALBOARD QUM OR AGENCY NAME <br />ARD <br />g LOCALAGENCY O OTHER <br />ADDRESS <br />/(act �/�z�crov f1v�. Srx, / <br />alp, <br />� NAME CONTACT PERSON � PFgNE ZIP <br />JE�eo <br />y� <br />❑ IAJICJOWN <br />ADDRESS1 <br />/ , �n' / /may <br />n <br />,, / gyp/ � /� �/ij�� <br />J786 A/ Q05+ TmUC—TREET I5 � L/%/� <br />cm •' 7YS_� ! <br />FACLITY NAME (IF APPLICABLE) P <br />OPERATOR <br />PHONE <br />ADDRESS 5 <br />CT q . <br />�e�g)�T/B „J ySZa <br />INIALO <br />C SSTREET TYPE R <br />OF AREA COMMERCIAL ORURAL TYPEOFSUSINESSS <br />�/� ETAIL FUEL STATIONsEM/Y�G-/E O RESIDENTIAL 0 OTHER O FARM <br />OTHERnL�, <br />g <br />AGE <br />LOCALAGENCY NCY NAME CONTACTPERSON PHD-NE <br />�y ;y <br />REGIONAL BOARD <br />PHONE <br />eelj e , <br />m <br />19 NAME QUANTITY LOST(GALLONS) <br />Cl im9p UNKNOWN <br />UNKNOWN <br />1- <br />DATEDISCOVERED HDWOIS D O INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CON)ITKINS <br />D.1 6PMI <br />I D o Vv v TANK TEST a TANKREMOVAL Ej OTHER <br />DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />wM <br />ry/_, <br />M o o v v LJ `"`KNOWN REMOVE CONTENTS O REPLACE TANK O CLOSE TANK <br />IHAS <br />DISCH BEENSTOPPED? REPAIRTANK REPAIRPPING CHANGE PROCEDURE <br />F3 <br />YES 0 NO FYES,DATE <br />41 O OTHER <br />M D o v <br />SOURCE OF DISCHARGE TANKS ONNLYACAPACITY MATERIAL CAUSE(S) <br />y� <br />O TANK LEAK O UNKNOWN /z DD Ari GAL. [D FIBERGLASS O OVERFILL O RUPTUREFALURE <br />O PIPING LEAK AGE YRS L"1 STEEL CORROSION O UNKNOWN <br />BOTHER F )..rF fjCq-s &oUNKNOWN O OTHER O SPILL EEJ'�THER ��AJGS <br />Me <br />CHECK ONE ONLY <br />{• <br />O UNDETERMINED SOILONLY O GROUNDWATER O DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F,g <br />CHECKONEONLY <br />¢` <br />O SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />O NO ACTION TAKEN Q 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 />0 <br />O CAPSITE(CD) O EXCAVATE& DEPOSE (ED) O REMOVE FREE PRODUCT (FP) O ENHANCED BIO DEGRADATION (IT) <br />❑ CONTAINMENT BARRIER (08) O EXCAVATE& TREAT LET) O PUMP& TREATGROUNDWATERM O REPLACE SUPPLY IRS) <br />O TREATMENT AT HOOKUP (HU) O NO ACTION REOUIRED(NA) O OTHER(OT) <br />T�-UeTFIe?e Sires 195-s025,Ve7rr TO a�-rcztir,u� rf+� <br />IVATt4e,6- exn�A1 or CpvT7,-?u10 -T7o.,J, f1S AeC� By 17l4= fh'P=oPK�/i/Zr <br />110 0049 ) <br />