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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY BE ICER <br /> YES NO REPORT BEEN FILED? ❑VFAH LOCALAGENCY <br /> L-] USE ONLY <br /> Es NO THEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPogr DATE REPORTED THIS INFORMATION TO LOCAL FICIALS PURSUANT TO SECTION 2S7B0)OF <br /> cASE# THE HEALTH AND SAFTY CODE {y <br /> DM I M It o C/y&y ' Q <br /> NAME OF INDIVIDUAL FILING REPORT SIGN <br /> m PHONE GNATURE CC 4"E4 V -DATE <br /> REPRESENTING ❑ N c- <br /> OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> p ❑ LOCAL AGENCY OTHER <br /> r <br /> ADDRESS xi s E/ <br /> ��✓a-=.- <br /> NAME SES <br /> crry <br /> y� ,<J_ CONTACT PERSON BATE IIP <br /> Sy ADDRESS // UNKNOWN ✓�J�ef 1-11 P,7-1� PHONE <br /> p�00 0 yV (� ,13y <br /> . GU <br /> STgeE� ��'l.�N L.tipi GPS( <br /> FACILITY NAME(IF APPLICABLE) STATE <br /> �^ nP <br /> OPERATOR <br /> O ,v( "T i PHONE <br /> ADDRESS <br /> oda � 7 <br /> F, CROSS <br /> STREET /u�� QTR � C" /�`y <br /> V V ❑E ESIDENTIOF AREAOAL O pTM qwL O INDUSTRIAL ❑RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> LOCAL AGENCY/ AGENCY NAME / p { ��❑�FA4RM_ -: OTHER <br /> ~w � LB Local , <br /> CONTACT <br /> N Nr✓�.'^"n+RJW"l.� PHONE <br /> / !� U7/f l 157i4/G (�D <br /> REGIONAL BOARD <br /> as <br /> PHONE <br /> NAME <br /> QUANT OST(GALLONS) <br /> ❑ UNKNOWN <br /> N <br /> DATE DISCOVERED ❑ UNKNOWN <br /> w HOW DISCOVERED ❑ INVENTORY CONTROL <br /> ❑ TANK TEST ❑ OTHEgRFACE M�Nl�70„gING ❑ VISANCE CONDITIONS <br /> y <br /> ❑ TANK REMOVAL <br /> DATE DISCHARGE BEGAN - <br /> METHODUSEDTOSTOPDISCHARGE(CHECK ALL THAT APP T) <br /> w M M o o y y ❑ UNKNOWN ❑ REMOVECONTENTS REPLACETANK E] CLOSE TANK <br /> 80 BEEN S <br /> HAS DISCHARGE TUPPED i ❑ REPAIR TANK <br /> D ❑ YES ❑ NO IFYES,DATE ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br /> w SOURCE OF DISCHARGE M MI C o y y ❑ OTHER <br /> j TANKS ONLY/CAPAC MATERIAL <br /> ❑ TANK LEAK ❑ UNKNOWN ®' CAUSE(S) <br /> j PIPING LEAK LL-&P- AGE B-� �yqS E] STEEL <br /> FIBERGLASS ❑ OVERFILL RUPTURE/FAILURE <br /> OTHER A ❑ CORROSION UNKNOWN <br /> ❑ UNKNOWN ❑ OTHER IIIR" <br /> �a CHECK NE ONLY S ❑ SPILL ❑ OTHER <br /> O UNDETERMINED SOIL ONLY ❑ ❑ <br /> GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> 2 N <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS <br /> Uy ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS [1] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DET AILS) ❑ NO FUNDS AVAILABLE TO PROCEED E] EVALUATING CLEANUP ALTERNATIVES <br /> o O ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSEED <br /> ( ) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CS) EXCAVATE TREAT <br /> ❑ IE>•! ❑ PUMPB TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) O OTHER <br /> h ( ddou ❑ (OT) <br /> AN: 1.TT <br /> �e obi¢ ,✓ spa lcrar, re- u <br /> VIM <br />