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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT l AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT.l HAVE <br /> r--] YES No E]YES ❑ REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REDPORT DATE CASE x TH�HEA ANSAFTY CODE. <br /> l/f/I D ////// (aj <br /> M M OD SD Y qy� <br /> SI E TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT RE <br /> Le keg 001)Wk-3 y <br /> a REPR�ING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY ME <br /> 1 � <br /> � LOCALAGENCY ❑ OTHER S G <br /> w <br /> ADDRESS , /�� <br /> F, O I S REET�© 1 'CITY STATE ` ZIP Gl <br /> w NAME (� -r- CONTACT PERSON ��/� PHONE <br /> z co I e`tT eliVwU ❑ UNKNOWN W T 06/i <br /> R< ADDRESS <br /> w <br /> `P D g-5 <br /> , <br /> STREET <br /> CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR &0 PHONE <br /> z C6 <br /> F" ADDRESS (n% 9 L�s� 'f t�7,. 1' to <br /> J / STREET 1 �y, , V • `I L C , <br /> �= ZIP <br /> CROSS STREET V TYPE OF AREA [:]COMMERCIAL ❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> N -Ii jWVV�L O-� I ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w p PHONE <br /> &24 <br /> w w REGIONAL BOARD /S <br /> CL ) <br /> (�) O NAME QUANTITY LOST(GALLONS) <br /> w NKNOWN <br /> Q J <br /> UIO (Z) <br /> [� ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCO ERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 61 'fi <br /> M b D D Y Y TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> QUNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w M M D D Y V <br /> HAS OISCH GE BEEN STOPPED? ❑ REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE UM 5M 0 DI Lt., 9-1 Y ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> fn <br /> D ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> KCHECK ONE LY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CH;�71NVESTIGATION <br /> NLY <br /> Q a IN PROGRESS(DEFINING EXTENT OF PROBLEM) F] CLEANUP IN PROGRESS [:] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> v N ❑ 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 /> 5 z ❑ CAP SITE(CD) ❑ <br /> EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> Er ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> s lei` iS% �'1 7"eSJ`' - �� a 1 a, DOO rxv 1 <br /> ` as'� GTQ S"// f�� sse <br /> w <br /> Sir c��'SS�SSri A�- <br />