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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE VES NO ❑YES NO .REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF REPORTDATE CASES THEHEALTH AND SAFTY CODE 0.1 M v �Y DATE NAM OF INDIVIDUAL FILING PORT PHONE SIGN�TURE w REPRESE G F-1OWNER�OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME O LOCAL AGENCY ❑ OTHER S- a ADDRESS //,o/ F A906�jtxJZIP NAME y1 A CONTACT PERSON PHONE UNKNOWN a ADDRESS � S ATE P FACLITY NAME(F APPLICABLE) OPERATOR PHONE I L V/nJ f2 (-26ei19�(o' a ADDRESS 9��C qCROSS TREET TYPE OF AREA COMMERCIAL O NDUSTRVIL O RURAL TYPE OF BUSINESS O RETAILFUELSTATKN L#91 Aic ❑RESIDENTIAL ❑OTHER ❑ FARM EO OTHER LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE uSi,yl REGIONAL BOARD PHONE (1) NAME QUANTITY LOST(GALLONS) ED-ldAKNOWN $$$� (2) �I ❑ UNKNOWN DATEDISCOVERED / HOWDISCOVERED F-1INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS N M D U^/O y v Co 'ANK TEST ❑ TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN �,/u. METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) w M M D r v Cg UNKNOYM E] REMOVECONTENTS E::] REPLACE TANK ❑ CLOSE TANK HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANKREPAIRPPING ❑ CHANGEPROCEDURE ©YES ❑ NO IFYES,DATE ml .1 DI DI YJ y ❑ OTHER w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) ❑ TANKLEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS O OV ILL O RUPTURE/FALURE 0 � IPIPING LEAKAGE YRS STEEL CORROSION O UNKNOWN O OTHER E O NOWN ❑ OTHER ❑ SPILL ❑ OTHER ly CHECK ONE ONLY 83 : ❑ UNDETERMINEDSOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) F CHECKONEONLY z� ¢s ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) UH O NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ N)FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATNES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ❑ CAP SITE(CID) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(M a 2 ❑ GONTAINMENTBARRIER(CB) O EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(01) ✓f{�✓ �i aS�SSi7t en Gtl i/! 1 e�ui red D�r�✓roti Q�i7�-�.