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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCYUSE <br /> ❑ YES REPORT BEEN FILED z -, /3 ❑ )Ni REBY CERTIFY THA?.C11M A 0ESIGNp7ER.GQV {N141NT EMPLOY AlgT1iAT 1 HAVE:,, <br /> YE REpp]( p}}�15 INFOEiMATION TO LOCAL afFfCU1L5 FUF�SUANt TQ SECTION 251801 OF. <br /> REPORT DATE <br /> CAS x THE HEALTH AND SAFT E <br /> 0 <br /> O M <br /> NAME OF INDIVIDUAL FILING REPORT PHONE ! SIGNATURE <br /> cavil V69-31116,91f -� <br /> RE=LOCAL <br /> G ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME /-/' / <br /> Ix AGENCY ❑ OTHER —o eig �� `�'L lA/t <br /> 4 <br /> Cc <br /> ADDRESS POB dO `� <br /> ZlEirIn �GY < sC71r1, 0srR`re�- r1 S <br /> P <br /> NAME CONTACT PERSON PHONE <br /> IN <br /> z�-, e I��C P`[�Cj❑ UNKNOWN G� [�Gl`e!/�- V� Z&6 716 <br /> r"7p»a ADDRESS 11 <br /> Lu <br /> 3. '(�- c zv, led S�IVaICJ4r , L. CA Qsays' <br /> CRY STATE ZIP <br /> FACILITY NAME(IF AFf'�.1CABLE) STREET OPERATOR PHONEe,,-u C P �tx7p�� <br /> a ADDRESS <br /> S 3 SerD•� �e �� [ �pV7 c�Lrn�a�[.rr�j �lS�Yj <br /> STREET <br /> errly <br /> y CROSS STREET - TYPE OFAREA ❑ <br /> /j� COMMERCIAL INDUSTRWL ❑RURAL TYPE OF BUSINESS ETAIL FUEL STATION <br /> �Uer�J� led ❑RESIDENTIAL ❑OTHER ❑ FARM THER L/n <br /> w LOCALAGENCY AGENCYNAME r CONTACTPERSON 1! PHONE <br /> w w REGIONAL BOARD <br /> `PHONE <br /> I! <br /> (t] <br /> Lu NAME i QUANTITY LOST(GALLONS) <br /> A; I NKNOWN <br /> (2) <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ UBSURFACE MONITORING ❑ NUISANCE CONDITIONS. <br /> w <br /> � TANK TEST ❑ TANK REMOVAL OTHER�++ u u � o�o r r ❑ !s I <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> } UNKNOWN REMOVE CONTENTS <br /> Lu u M o o v v ❑ ❑ REPLACE TANK ❑ CLOSE TANK <br /> NAS DISCHARGE BEEN STOPPED Z ❑ REPAIR PIPING + CHANGE PROCEDURE <br /> ❑ REPAIR TANK ❑ <br /> p ❑ YES ❑ NO IFYES,DATE - <br /> ml mi DI DI r Y ❑ OTHER <br /> SOURCE OF DISCHARG4?-UNKNOWN <br /> TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK D GAL. ❑ FIBERGLASS E:] ' <br /> OVERFILL ❑ RUP ARURE <br /> � <br /> El PIPINGLEAK' AGE YRS ❑ STEEL <br /> ❑ <br /> ❑ OTHER UNKNOWN ❑-OTHER CORROSION UNKNOWN <br /> w� CHECK ONE ONLY SPILL ED OTHER <br /> v ❑ UNDETERMINEDafSOIL ONLY ED GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE D Y <br /> azy I <br /> ❑ INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Q°' NO ACTION TAKEN ❑ POST CLEANUP MONITOR ING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Z o CAP SITE(CD)Q ❑ ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 3 TREAT(ET) TREAT GROUNDWATER GT) El REPLACE SUPPLY(RS) <br /> E:] TREATMENT AT HOOKUP(HU) E::] NO ACTK)N REQUIRED(NA) THEA(OT)_ � <br /> y w <br /> ga0a �u/ rey. J�-crso/�:zr �k- leaf de rcfor in 5- 1/A .ate 1 <br /> LrO fCir•:inrsf�v�, p eX CLivaY�GG! .Boll. FLr!-�Ae <br /> c Si~�r �4sse'ss�.L���. cuE!/ <br /> G! Llex 19'iI co jrig.,�u 7<<�r, ee_s ! <br /> ),e f a o-ed 4X Ct��j ori% �2c�c Ila tiro! G�yL Ir G Ksc os l,a�] i <br />