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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY - <br /> REPORT BEEN FILED? LHEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> [:DYES Ix NO E::]YES ❑ NO .REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251007 OF <br /> REPORTDATE CASEA THE HEALTH AND SAFTY CODE <br /> rp ,l;U n �i I D <br /> M7/, 0 fr Iv-� Y STONED SATE <br /> NAME OF INDIVIDUAL FILING REPORTPHONE SIGNATURE <br /> �M R K d" W if-3 � Z&V411, <br /> REPRESENTING ❑ OWNEWOPERATOR REGIONALBOARD COMPANY OR AGENCY NAME <br /> D LOCALAGENCY E:] OTHER SAN `- f} Nl%d T 1. H A -rlg6r <br /> 6 <br /> ADDRESS < O S <br /> ZIP IN <br /> NAME /}y /� may" CONTACTPERSON PHONE <br /> m� O F-( <br /> OF <br /> r 16FC�a�❑ <br /> UNKNOWN l /.. e / /�VYL� / -V <br /> ADDRESS o M4 /1 / 7VAI C S-706160 /EU CITY ap <br /> FACLITY NAM PAPPLICABLE) OPERATO PHONE <br /> < - Of- S fOpGp�C74vi 9y1s--62� <br /> ADDRESS ( O 1 2 Zb 0 J Dm <br /> CROSSSTREET �J TYPE OF AREA ❑COMMERCIAL Q INDUSTRIAL ❑RURAL TYPE dF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY ` AGENCY NAME OONTACTPERSON PHONE <br /> omu/l✓l-oec, I LTA Pa3yz <br /> REGIONAL BOARD PHONE <br /> (96)36/--Q o0 <br /> ur (1) NAME 0UANTRY LOST(GALLONS) <br /> X$ D/e ❑ UNKNOWN <br /> 9 (2) <br /> y ❑ UNKNOWN <br /> i DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �+M M / o / D y y ❑ TANKTEST CDX< TA FkC REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CK CLOSE TANK <br /> w M M D D Y Y <br /> p HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPING ❑ CHANGEPROCEDURE <br /> ,�❑ ❑ YES ❑ NO IFYES.DATE MI M DI 0 YJ Y [D OTHER <br /> u� SOURCE OF DISCHARGE (TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ E::] TANKLEAK UNKNOWN l Z 0 GAL. FIBERGLASS ❑ OVERFILL ❑ RUPTUREFAILURE <br /> ❑ PIPING LEAK AGEX'-/0YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHEfl <br /> w 11l CHECKONEONLY <br /> U� k UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY P WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> u% ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> j 2 ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ' ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> TREATMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> k Si)4G b& uiRea �d�rnLine <br /> the HaftivV avcd <br /> ! ti /;e <br /> HWM(MM <br />