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i' UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ';FOR LOCAL AGENCY USE ONLY YES No REPORT BEEN FILED? YES THEREBY OERTIFY THAT I AW A DE' 6WED GQVERNMENT.:EMPLOYEt`AND CHAT)HAVE ❑ NEF�gRIE(?T)i15.INFdRM14FiAN TO URAL OFFIGfAIS PURSUANT 7p,SGTfO1(251807.OF REPORT OATS CASE# THE HEALT}i ANO SAF1Y CODE DM CJ y y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE > D z W9) q(iS'-:3q 39: REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY �-O^^RR�`�AGENCY NAME c-otvjYo/q n1,�l t4k p LOCAL AGENCY ❑ OTHER Qty�/OGc .(//7 Lo ." -C.Cc., 4 OyS f�• a � ADDRESS. CITY ��C/C�/C TV T 1 sr,TE A zm NAME /� CONTACT PERSON /PHONE w y/1f I/I may} n 7"C-. UNKNOWN 1/lr a S R .ADDES l a �y �/� 1 f _ I ¢ ��FgEET� CITU G,r STATE - pp FACILITY NAME(IF APPLICABLE) OPERATOR PHONE E a ADDRESS lcrr.y ley, CROSS STREET TYPE OF AREA COMMEACIAL INDUSTRIAL ❑RURAL TYPE OF BUSINESS.' ❑ RETAILEUELSTA7KX1 p,`.❑RESIDENTIAL E]OTHER ❑ FARM �THER J"C? )- LOCAL AGENCY AGENCY NAME OONTACT PERSON PHONE z W u �� ' r� r r l 6 z� X02)alb -3q w REGIONAL BOARD PHONE (II NAME QUANTITY LOST(GALLONS) U d DdNKNOWN O UNKNOWN DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL .;❑ SUBSURFACE MONITORING ❑ NUISANCE OONDITIONS 0.1 0 8',l ❑ TANK TEST TANK REMOVAL ❑ OTHER � n�S �l in DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) w .. M M o o v W v VKNa ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK a HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE ❑ YES ❑ NO IFYES,DATE M M D 0 Y yl ED OTHER ' N SOURCE DISCHARGE TANKS ONLYrAPACITY MATERIAL CAUSE(S) TAANK LEAK ❑ UNKNOWN '?C50 O GAL. ❑ F19EAGLMS ❑ OVERFILL �RUR,,IREFAILURE ❑ PIPING LEAK AGE YRSCORROSIONWN C❑ OTH R ❑�[<NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER LCHECK E ONLY p UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) � CHECK EONLY zy Q a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) v N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ED EVALUATING CLEANUP.ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) azQ ❑ CAP SITE(CD) ED EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATioN(IT) ~ ❑ CONTAINMENT BAR RIER(CB) ❑ EXCAVATE R TREAT(ET) ❑ PUMP'&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) 0 TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) a HS0 05(447)