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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES EOR LOCALAGENCY:USE ONLY: <br /> REPORT BEEN FILED? 1:}iER1 BY CERTIFY THAT(AM A pES(GNATI GOVERNMENT EMPLOYES ANDTHq ♦HAVE <br /> YES �NO YES Q ND REPORTER T.NIS INFOEMATION TO AL.OFFICIALS PURSUANT TO SECTION 25180:7 OF: <br /> REPORTDATE CASEi �� <br /> M JM o r v SIGNED DAFE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE ' <br /> 14 1 <br /> m . <br /> W REPRESENTING a OWNER/OPERATORREGIONAL BOARD COMPANY OR AGENCY NAME ��(' (� -W <br /> LOCAL AGENCY 0 OTHER ('t f c, F,yCIV r r t l{ <br /> IL Ix <br /> A DRESS (1/ n 2_ n /��J��� /) `/�j(�)�'jLJ��O� <br /> �{ V 1 &OX S�EQy C j�ajAL-rA STATE I ! ZIP <br /> L4 <br /> NAME I CL^rs ! E CONTACTPERSORRN'N F PHONE <br /> y�p� U--,- <br /> ` p0 <br /> N '/2 S i Ch - UNKNOWN b � �') 0 <br /> zQ <br /> g Qa ADDRESS ` ////- ////�}A�- <br /> 2 i /--(/ STREET V • � CRY SPATE 4fA <br /> FACILITY NAME(IF APPLICABLE) 77 OPERATOR / PHONE <br /> ADDRESS <br /> STREET/ � � / CRY • JCOUNTY leP <br /> Fn CROSS STREETTYPE OF AREA COMMERCIAL 0 INDUSTRIAL Ej RURAL TYPE OF BUSINESS Z RETAIL FUEL STATION <br /> 1 -7-� 1 O RESIDENTIAL OTHER Q FARM 0 OTHER <br /> - LOC I�LEbi keA E �AMSCONTACT PERSON PHONE /� [� <br /> zw Y lk-6Lf+'; / IV G <br /> w <br /> w <br /> / <br /> W REGIONAL BOARD PE <br /> ��/a a l.� <br /> (�) NAME QUANTITY LOST(GALLO ) <br /> w <br /> ZO W ��J' ` (✓ -mv�e, UNKNOWN <br /> Q J <br /> r(2) <br /> xyle, l� ANKNOWN <br /> F- <br /> DATE DISCOVERE r i�/ HOW DISCOVERED INVENTORY CONTROL Q SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> Lu <br /> [f M M o D �v v E:] TANK TEST Q TANK REMOVAL OTHER �! / b4> /V <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN Q REMOVE CONTENTS E:] REPLACE TANK a CLOSETANK <br /> W M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING F CHANGE PROCEDURE <br /> 0 0 YES E:] NO IF YES,DATE M M D o v y OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> F7 TANK LEAK UNKNOWN GAL, Q FIBERGLASS a OVERFILL a RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS 0 STEEL CORROSION UNKNOWN <br /> 9) 0 OTHER UNKNOWN 0 OTHER SPILL EJ OTHER <br /> Lu w CHECK ONE ONLY <br /> O UNDETERMINED SOIL ONLY GROUNDWATER a DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK NE ONLY <br /> z� <br /> Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESSF--] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> D 0) F--j NO ACTION TAKEN E:] POST CLEANUP MONITORING IN PROGRESS a NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4 z F--] CAP SITE(CD) EXCAVATE b DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> 5O <br /> w 1- F-1CONTAINMENTBARRIER(CB) EXCAVATE&TREAT(ET) P MP E TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) <br /> NO ACTION REQUIRED(NA) ./ OTHER(OT) <br /> So�� s�+�►.1 p/� Gr1/� k ri n y 3�L�� �/��;/�:v� o�' s�i f,�o,��a✓�S <br /> z {+e?Vel Go n!-fi4 r+-v��/A Ti v�✓, �U�P�'" •�- sr r�i�" 40-e53%41 <br /> p�•� 1�'��L he, <br /> '`�u/%6 eek ' �C,2r�+i int. 0 e. y �-�- �t.-GcA��� + o,� G i✓7 .rr�r <br /> 8 red�. r�c a/ b,/ <br /> HSC 05(W <br />