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0 9 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO YES <br /> BEEN FILED? YES �NO I HEREBY CERTIFY THAT I:AM A DESEGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REFORTED THIS INFORMATIONJO LOCAL OFFICIALS PURSUANT TO.SECTION 25180.7 OF <br /> REPORT DATE CASE# THE HEALTH AND SAFTY CE <br /> �l AY ) Y SIGNED DX7Tt <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SVGN URE <br /> 0 REPRES ING ❑ 0WNEFVOPERATOR ❑ REGIONAL BOARD COMPANY OR ENCY NAME <br /> °C LOCAL AGENCY L_j OTHER , . . <br /> O <br /> ADDRESS <br /> X Loof <br /> � <br /> ? p <br /> STREET <br /> Lam'f <br /> STATE ZIP <br /> NAME CO/TA�C�T�PEERISONN P�H}O�NE, �+y <br /> Fn <br /> i-- 4 �vlrl dr'1 ❑ UNKNOWN <br /> IL <br /> d ADDRESS /y f////Jff/// /y/ �� /��] ffJ <br /> Lu I I l <br /> CL' 7 � ✓✓ '-i Cf1y CITE r P <br /> FACILITY NAME(IF APPLICABLE) OPERATORPHONE <br /> � (/ <br /> C AooREs J— J2-D—T' <br /> J i ° V iA�11y�4T- S <br /> crrr Daur+rr zip <br /> NCROSS STREET TYPE OF AREA COMMERCIAL DUSTRIAL RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER FARM OTHER <br /> LOCALAGEN/CY AGENCY NAME CONTACTPERSOI`j PHONE 7 <br /> zw 5. . [�• <br /> Lu <br /> LU <br /> REGIONAL BOARD PHONE <br /> EL <br /> W <br /> ;1) NAME QUANTITY LOST(GALLON <br /> W <br /> w � UNKNOWN <br /> d J <br /> m Z (2) <br /> cn KNOWN <br /> z DATE DISCO RED T �/' HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M , M 76 ✓ D (J r v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M D D r r <br /> UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK �GLOSE TANK <br /> ¢ M <br /> p HAS DIS ARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p <br /> HAS <br /> ❑ NO IFYES.DATE � - M C-o y D Y1 v ❑ OTHER <br /> Lu SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSES) <br /> CA <br /> ❑ TANK LEAK UNKNOWN 0 GAL. ❑ FIBERGLASS OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPINGLEAK AGE_YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER �NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> LU w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> zN <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)w 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 /> 0 z ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED{ ❑ REMOVE FREE PRODUCT(FP} ❑ ENHANCED BIO DEGRADATION(IT) <br /> w <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ¢ ❑ TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) OTHER(OT) <br /> to /, pe70GceA �...L.L '-i�L-/21% l� / t r`'tr}-� . Si, L'c�.� <br /> L <br /> HSC 05(W <br />