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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK) i CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SEPVICES FOR LOCALAGENCY USE ONLY ! <br /> REPORT BEEN FILED? 1HEREBY CERTIFY THAT I AM A DESK�TlA7ED GOVHiNMENC EMPLOYEEAND7HAT!HAVE: <br /> YES No VES Q NO REPORTED THIS WFORMAlM TO LOCAL OFFICL43 PURSUANT T0rSECTION 25)$V OF: '. <br /> REPORTDATECASE* THEHEALTH E. <br /> M � 8v V Y SIGNED TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> le <br /> a REPRESE ING O OWNERfOPERATOR O REGIONALSOARD COMPANY OR AGENCY NAME /�,/�,D <br /> LOCAL AGENCY OTHER +*✓f• ��a "�`^"`^ ' v ✓�� �' <br /> i <br /> ADDRESS <br /> / I/J //�� <br /> W D/ / STiiEET �//yt 6�rfry I ,/• - / <br /> NAME n CONTACT PERSON g PHONE <br /> /�/� � <br /> W 7 1 d- UNKNOWN `16 ) 6 <br /> i ADDRESS ZQ <br /> ¢ SS C!, 1 E� CrtV STATE DP. <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> mCROSS STREET TYPE OF AREA OCOMMERCIAL a INDUSTRIAL O RURAL TYPE OF BUSINESS O gETAIL FUEL STATION <br /> /-' <br /> =RESIDENTIAL =OTHER O FARM Q OTHER <br /> LOCALAGENCV V., AGENCY NAMECONTACT PERSON - PHONE <br /> w `Sam � ala I �P. Des Tcf�- katALL t &I k llu 1 �✓o�3Yao <br /> w w REGIONAL BOARD <br /> PHONE <br /> lo C <br /> (�) yin /� (Leaded LNAME QUANTITY LOST(GALLONS) <br /> Ow 1 e f�l-r PQ P QJ LT(�ONK/NOWN <br /> If > <br /> (2) <br /> UNKNOWN <br /> DATE DISCOVERED �([y HOWDISCOVE RED Q INVENTORY CONTROL SUBSURFACE MONITORING NJISANCECONOITIONS <br /> w M A- /o �� `� r TANK TEST O TANK REMOVAL BOTHER <br /> a <br /> DATE DISCHARGE BEGAN K�/'1 MET�HjO/DySED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o v Yl u UNKNOWN L�✓J REMOVECONTENTS O REPLACE TANK CLOSE TANK <br /> 4 HAS DISCHARGE BEEN STOPPED? REPARTANK REPAIRPPWG CHANGE PROCEDURE <br /> S <br /> Eo." <br /> E5 O NO IFYES,DATE M) M o� o v r OTHER ' <br /> w SOURCE OF DISCHARGE TANKS)ONLYrAPACITV MATERIAL CAUSE(S) <br /> TANK LEAK �. UNKNOWN !I- 000 GAL. Q FIBERGLASS O OVERFILL a RUPTUREFAILURE <br /> F PIPING LEAK AGE YRS Q STEEL �RROSION UNKNOWN <br /> O OTHER ®UNKNOWN OTHER a SPILL = OTHER <br /> ww CHECKONEONLY <br /> U� O UNDETERMINED dSOII:ONIV GROUNDWATER DRIKKWG WATER (CHECK ONLY F WATER WELLS HAVEACTUALLV BEEN AFFECTED) <br /> F y <br /> CHECK ONE ONLY <br /> ¢a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS E::] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> NO ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVAILABLE TO PROCEED = EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 2 = CAP SITE(CD) O EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> W <br /> O CONTAINMENT BARRIER(CB) O EXCAVATE B TREAT(ET) PUMP$TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Q TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA)- O OTHER(OT) <br /> u� <br /> w lanh' i ens�ecf�'�rL) remo)lad re <br /> r� rllei^ e �vSih <br /> Lab rsu/fs s ct /iY" <br /> _. _ RSLA514S11 <br />