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1 � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED? YES NO l HEREBY CERTIN:THAT E RM A fl�51GNATEa GOVERNMENT.Eh�PLaYEf AND p)AT#}TAYE <br /> E] ❑ QEP�R7ED T]�[5 NFOFIMAION TO 1 pCAL <br /> EC <br /> pFF1CfALS PURSUANT TO STION 25184 9 OF" <br /> REPORT DATE CASE x THE HEALTH AND SAFTY CODE <br /> plx <br /> 1 <br /> /M -I DI C!R Y �v SIGNED':'i .... <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> C / D7-- P09)LW-3VIS S I <br /> a REPRESENT G ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANYORAGENCY NAME <br /> Ir LOCALAGENCY [-] OTHER ����� ?�� Se0rU'z� <br /> a <br /> Cc ADDRESS ff / [ /J <br /> IFl7 ///7 A CfTY AVC-k STATE ZIP S�0 <br /> NAME CONTACTPERSON PHONE ��, y0 <br /> co <br /> � /_ ► // / <br /> z¢ be////77 /)7T DY � UNKNOWN <br /> CL ADDRESS r <br /> tu <br /> Q -7 1 C S' 9sto <br /> STREET C't !'J?in Pr CITY /v,yl�C4--f � STATE C14 ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE f+� 3 Y 0 <br /> z Cir 3 �p�n �u Y� Oy 1 y��Yo yj <br /> ADDRESS <br /> / p <br /> cp STREET / I/'l G COUNTY <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS Z RETAIL FUEL STATION <br /> r 7'1P-- ❑RESIDENTIAL ❑OTHER IE::] FARM ER <br /> y LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Lu <br /> 6/G �� rc�I 0� ( 11Y��3S &,F <br /> Lu <br /> REGIONAL BOARD PHONE <br /> (I) NAME QUANTITY LOST <br /> N (7UNKNOWN <br /> 0 <br /> 20 m <br /> NKNOWN <br /> DAVE DISCOVERED <br /> n o YJ <br /> Lu v � ED <br /> ❑SCA TANKTEST ❑ TANK REMOVAL <br /> ❑❑ OTHER RFACE MONITORING ❑ NUISANCE CONDfTpNS <br /> 1 ml <br /> DATE DISCHARGE BEGANMETHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u µ o I) v r Col /UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IFYES,DATE o o r Y ❑ OTHER <br /> ER <br /> SOURCE OF TANKS NKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> gF] TANK LEAK UNKNOWN 1-le- 101C— GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUP AILURE <br /> ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHERUNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECK ONE ONLY <br /> a a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT Of PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> H ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATI <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHA B DE (IT) <br /> 00 <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE a TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(G7) ❑ RE ESU <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OT) <br /> zC� ccfGc�� Cy�t� <br /> Lu <br /> Coi.r�i.7u��im ds Y��u�i=cel /a y cl��.vrf-, a�f�t �y• is u g R, fix•��,k s <br /> NSC M(4/871 <br /> �( 1 '122 <br />