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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? O YES NO IHEREBY CERTIFY THATNT.I AM A.DESIGNATED GOVERNMEEMPLOYEE AND THAT I HAVE <br /> YES ENO <br /> REPORTE THIS INFORMATICN TO LOCAL OFFICIALS PURSUANT TO SECTION 25007 OF <br /> RyEL)POflT�DJATE R CASEt THE TH AND SAFTYDE: <br /> YM� 2M 2 `�o '9 r �Y SIG EC /ATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE /.—(. �j_ / SIGNATURE <br /> m <br /> a REPRESENTING OWNER/OPERATOR F7 flEGIONALBOARD COMPANY OR AGENCY NAME <br /> It <br /> ❑ LOCAL AGENCY ❑ OTHERffi - � n// G.O' <br /> ADDRESS <br /> /390 K//GGL7K1 FSA 1� RS- /P-t '9 CC Co <br /> ,eL cn 4 G��•y'2!J <br /> STREET WY <br /> NAME CONTACTPERSON gAPHONE TE ZIP <br /> Zy� ❑ UNKNOWN (� K <br /> n y ADDRESS � <br /> �, o • 8ox 4oz3 cosCcc�1� c <br /> STREET 94124 <br /> Cm <br /> FACILITY NAME(IF APPLICABLE) OPERATOR RATE PP <br /> PHONE <br /> ADDRESS <br /> !o/3 / Gs4Cl�/c �Tocic jo. se ! ✓off//� 95207 <br /> �u sTREUEET - cm <br /> y CROOSSSSS'JTREET - -- TYPEOFAREA COMMERCIAL ❑INDUSTRIAL❑RURAL TYPEOFSUSINESS RETAIL FUEL STATION <br /> "� �'/ ❑RESIDENTIAL ❑OTHER - ❑ FARM ❑ OTHER <br /> y LOCALAGE�Py AGENCY NAME OONTACTPERSON PHONE <br /> EW✓/209(0E 54,6- <br /> w REGIONAL BOARD <br /> y PHONE <br /> 3 <br /> ( <br /> NAME QUANTITY LOST(GALLONS) <br /> Tf'UNKNOWN <br /> a (2) <br /> _ ❑ UWNOWN <br /> i DATEDISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONSOM 2M 40 .1')v 0,1 ❑ TANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> S DATE DISCHARGE BEGAN - / METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w N M o - o v r Irl UNKNOWN EREMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED? . - ❑ REPAIRTANK ❑ REPAIRPWWG ❑ CHANGE PROCEDURE <br /> p EYES ❑ NO IFYES,DATE ul 2M �o 8o19v0v ❑ OTHER <br /> SOURCE OF DISCHARGE _ TANKS ONLYECAPACITY MATERIAL CAUSE(S) <br /> DeTANKLEAK ❑ UNKNOWN 14 GDO GAL, ❑ FIBERGLASS ❑ OVERFLL ❑ RUPTUREFAILURE <br /> 2 ❑ PIPINGLEAK t,❑ p.LL�D AGE��YRS - STEEL E] CORROSION UNKNOWN OTHER g / ❑ UNKNOWN ❑.OTHER <br /> ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY _ <br /> on <br /> ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> ¢s SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E:] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> t�y ❑ NOACTK)NTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED VALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP (CD)SITE <br /> w ❑ EXCAVATE 8 DISPOSE(ED) _ ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Hca ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATEBTREAT(ET) ❑ PUMPB TREAT GROUNDWATER(DID ❑ REPLACE�S.,U�PP�LY�(R/S) <br /> F7 TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) (/64EA(a66C/ <br /> A/-/- 7,4.c/lc3 Ax/b 7D BE �EOG9cEd ulrr.4 bC416GE w.ac.Z- <br /> F/�c�:CrcAss Y r(rf/TT/.clCi /� X� OcrPE�s� �t/x11Z s4- 0+Z14%4S <br /> ,�C-r�,cic/�5 BY T fa/T GFS �i�ssoc. <br /> �ac�l� <br />