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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORTSEEN FLED 7 I HEREBY CERTIFY THAT I AM AfDESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE'. <br /> YES NO �iES (] ND REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 2618V OF <br /> (/REPORTDATE CASE# THE HEALTH Abp £ (Q�[),1��j(m <br /> OR M M D ?,10 Y SIGNED f' --`=T Z pT7E <br /> NAME OF INDIVIDUAL FILIN9,REPORT PHONESIGNAJRE <br /> CAaril� w, — Q ) 6G 39s'� Lk 12,vlu� <br /> cREPRESENTING O OWNER(OPERATOR O REGIONAL BOARD COM12ANY OR AGENCY NAME �/- <br /> 0 d LOCALAGENCY O OTHER N jeowkN <br /> ADDRESS / <br /> �v ✓ y/ • I/-91HEEf CITY C BfATE vp <br /> NAME NTACTPERSON PpHO7N(jE p <br /> i UNKNOWN <br /> S n ADDRESS <br /> w P D. J3ex 300,0 <br /> a MCRY ATE75213- Ovo,Po <br /> STREET K. O!J <br /> FACILITY NAME(IFF APPLICABLE) OPERATOR PHONE <br /> co IDI / f1L N Kk K �R '�3�i1 <br /> ay3 /�Cq <br /> S�o 'R <br /> m CROSSSTREET <br /> t� LOCALAGENCV AGENCY NAME ACTPERSON PHONE <br /> 3N .N ubl;� a ,« (cud(+s E �,..-t' rz� ) We 39/0 <br /> REGIONAL ARD /PHONE <br /> y o (1 NAME QUANTITY LOST(GALLO ) <br /> O( ,TIS Lf/� UNKNOWN <br /> UNKNOWN <br /> W /DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> IAI <br /> M M D Y Y O TANK TEST O TANKREMOVAL OTHER <br /> UL o�CIru P 7/- <br /> DATE DISCHARGE BEGANMETHgD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D v USED <br /> ,yu{ REMOVE CONTENTS a REPLACE TANK O CLOSE TANK <br /> O HAS DISCHARGE BEEN STOPPED 7 O REPAIR TANK O REPAIR PIPING E:] CHANGE PROCEDURE <br /> o YES [:] NO IFYES.DATE MI M DI D YJ Y OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> 29 O TANKLEAK v/UNKNOWN O OVERFILL O RUPTURE/FAILURE O SPILL <br /> ❑ PIPING LEN( O OTHER O CORROSION lzr UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> ya <br /> F-1 UNDETERMINED O SOILONLY O GROUNDWATER 0 DRINKINGWATER. (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> 2� O NO ACTION TARN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTEDa POLLUTION CHARACTERIZATION <br /> tiN O LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> REMEDIATION PLAN F-1 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE B DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> wQ OI4E6�LRrwoErMq �) <br /> CAPSITE(CD) O E%CAVATEBTREAT(ET) 0 fNMPBTREATGROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> O CONTAINMENT 13ARRIER(CB) O NO ACTION REQUIRED INA) G' TREATMENT AT HOOKUP(HUI O VENT SOIL(VS) <br /> VACUUM EXTRACTIVE) O OTHER(OT) <br /> olvrE 0 <br /> �JroP pS4¢ .. S,r.J�,� D!('7N?5 eomak,41 u�, sod <br /> Gs575maN,'� f-P�l,(/tYrYG-, F,*rww' e. -/AV <br /> g ('cw'�Y+'✓)ir.a"�7D�� �Ys �/r� � f"� cip�)-ef�rla�c- �u/R9�af�y G�tNrIeS „ <br />