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fb <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVI96 FOR LOCAL AGENCY USE ONLY <br /> YES NO REPORT BEEN FILED? YES Ey NO I HERESY:CERTIFY THAT I AM A DESIGNAT>D GOVMNMENT.EMPLOYEI AND THATI.HAVE'. <br /> DEPORTED THIS I.NFORMATION.TO.LOCAL OFFICIALS PURSUANT TO.SECTION 25180:7 OF <br /> REPORT DATE CASE* THE HEALTH AND SAFTY CODE. _ <br /> owl qml 50 `y9yi SIGNED iA3TE <br /> N OF INDIVIPan DUAL FG REPORT PHONE SIG"E <br /> � q69-�v � l <br /> 0 REPRESENT G OWNERIOPERATOR ❑ REGIONAL BOARD COMPA OR AGENCY NAME <br /> p OCALAGENCY ❑ OTHER <br /> a <br /> ADDRESS <br /> �/^'^f (/��/�y/�) Cv�1 -L] }yam f�L//1�111 9 J��}}1/�J► <br /> y ✓ N � 6`_ . " Sj0c � / V �./cv C SATE I 5--'Z�P6 <br /> NAMES ci f� /� /] TACjT1PERSON /J PHONE <br /> J <br /> Z C� 1 j V uL u1 ❑ UNKNOWN 1 f G 20!) 93 •l�Ilal <br /> R Qa ADDRESS <br /> /��� /k�I ��////�� <br /> Lu <br /> DV -r) STATE Ep <br /> GI 5 Z <br /> FACILITY NAME(111�P�CABL� �� OPERATOR �� <br /> z lllyly I3I�i�i <br /> Q AD ESS <br /> 3 e �. mTR� -, -lK- S-�1. y 9szoz <br /> CrTy <br /> CROSS STREET TYPE OF AREA COMMERCIAL ITFDUSTRiAL RURAL TYPE OF BUSINES RETAIL FUEL STATION <br /> U) 4rdf)+ ❑RESIDENTIAL OTHER ❑ FARM OTHER <br /> W �AL!}GENCY �i AGENCY NAME CONTACTPERSON PHONE <br /> y lkN(,G✓1 C� H <br /> W� <br /> M LuRFr(iIONyL BOA. RLa A � ^ PHONE <br /> N {ty NAME QUANTITYLOST(GALLONS) <br /> LU <br /> 0� a6o il7� UNKNOWN <br /> N ❑ UNKNOWN <br /> bA7E DISCOVERED HOW DISCOVERED ❑ vENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z fIS r{j' <br /> 2 DM !M o o 8Y • y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN � REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> W M .1 <br /> q D Y Y <br /> p HAS DI ARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING E:l CHANGE PROCEDURE <br /> p ES ❑ NO IF YES,DATE .1 ZI1 .18 yy ❑ OTHER <br /> W SOURCE OF DISCHAIIGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> F7 TANK LEAK UNKNOWN l'p OD GAL. FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> U¢ ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> j ❑ OTHER /UNKNOWN OTHER SPILL OTHER <br /> W W CHECK 6 ONLY <br /> a <br /> O UNDETERMINED ❑ SOIL ONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z� <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U y NO ACTION TAKEN P057 CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE S TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(G7) ❑ REPLACE SUPPLY(RS) <br /> TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> N <br /> z <br /> z <br /> W <br /> HSC 05(W) <br />