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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 /> EMPLOYEE AND THAT I�I NO REPORT BEEN FLED4 I HEREBY CERTIFY THAT I AM❑YES E] NO REPORTED THIS NFORMATIONATO LOCAL OFFICIALS o <br /> GOVERNMENT <br /> ❑ �S I� ANT TO SECTION 251BA7AOF <br /> CASEI T�I -H LT NDS ODE /C <br /> REPORT DATE J'j-f/-✓ <br /> OM M O o Y V SIG ED DATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE ISIGN RE <br /> o,�euA, am 4t0 �f50 <br /> O REPRESENTING O OWNER•OPERATOR E::] REGIONAL BOARD COMPANY <br /> OR AGENCY NAME <br /> LOCALAGENCY ❑ OTHER 4TVQ �' <br /> R <br /> ADDRESS <br /> �O E �� O I STHEEf CRY STATE J/A-�� ZIP <br /> CONTACTPERSON PHONE <br /> NAME <br /> @gh� NAME rvt K an e+ a,l ❑ UNKNOWN �$ct l eewL han ) 334-3d?/ <br /> S<n ADDRESS <br /> IN All E .^t h-*. 1 • CRY SATEy1/Xy <br /> O PP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> - FFRMAR ,'E A CO c <br /> ADDRESS <br /> d N . eroV"E7] <br /> SOS• ill n C IffY R <br /> m <br /> CROSS STREET AREA T1Yl COMMERCIAL Q INDUSTRIAL O RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> SIDENTIAL Q OTHER Q FARM O OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> sanSo �i 1�5-E �Dcuss91�J68-3USd <br /> REGIONAL BOAR /PHONE <br /> 2L <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> UUNKNOWN <br /> (2) ❑ UNKNOWN <br /> N <br /> DATE DISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Y <br /> k M M 0 Y <br /> [-] TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> }i M M o o r r ❑ REPAIR TANK ❑ REPAIR PIPING <br /> ❑ CHANGEPROCEOURE <br /> p ��DISCHARGE <br /> YES O ENSTOPPED <br /> TO VES,DATE M M o o v v —(Z,, t N� yy)y�,,� <br /> �, OTHER / G(M.C. Ty'`'y I <br /> SOURCE OF DISCHARGE TANKS ONLY.CAPACITY MATERIAL CAUSES) <br /> TANKLEAK D< UNKNOWN / GAL- ❑ FIBERGLASS O OVERFILL ..E] RUPTUREFALURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL CORROSION 17(,` UNKNOWN <br /> O OTHER UNKNOWN ❑ OTHER O SPILL O OTHER <br /> w� CHECK ONE ONLY <br /> O UNDETERMINED O SOILONLV GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Fgg CHECKONEONLV <br /> 2C Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESS a SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Um NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONIS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION IT) <br /> wO CONTAINMENT BARRIER IDS) O EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) E::] REPLACE SUPPLY IRS) <br /> O TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) OTHER(OT) <br /> LA-t iQ.l �-tr VOL QMQ� i l9M " �-�-�- <br /> Q��k v`S� a V,6 LAAAI�.tA."- C IIL40�,A"12 Pfdo 4j� 049 ANA <br /> NScosl447 <br />