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e <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> r7YES No REPORT BEEN FILED 7 DYES ❑ NO I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT(HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORT_DATE CASE <br /> THE HEALTH AND SAFTY CODE <br /> D Y Y SIGNED - DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> O REPRESS TING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> L <br /> � LOCAL AGENCY ❑ OTHER �� PH <br /> a <br /> ¢ ADDRESSc'20 <br /> STREET CITY STATE ZIP <br /> NAME C f�,, CONTACT PERSON PHONE <br /> R <br /> in- <br /> coV14 .f t`1�C -ft!i Cr C. ❑ UNKNOWN1 CEJ 1` G��Y t CSL ) <br /> ¢ ADDRESS I c (/ 6 <br /> LliQ i <br /> ' 3 RE CITY STATE ZIP <br /> _ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br />.. U ADDRESS _S. f o C. �/T c •ti's J t ��c�f M,. <br /> J tf STREET Arry CWNTYP <br /> 0) CROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS, ❑ gETAIL FUEL STATION , <br /> i <br /> _ e /w/lt ❑RESIDENTIAL ❑OTHER ❑ FARM [ZOTHER iUb• -I y av) C <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> to .:r _. ^ <br /> wLu <br /> REGIONAL BOARD PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> uJ L!C 1 NKNOWN <br /> yl F O (2) <br /> ❑ UNKNOWN <br /> I- DATE DISCOVERED HOW DISC01(ERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> N ! <br /> M "�M D '-1D Y ` y E2"TANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q � ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> UNKNOWN <br /> W M M D D V Y <br /> p HAS DISCHARGE BEEN OPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p ❑ YES [:e NO IF YES, ATE M M o -1 y I y �OTHER <br /> y /C <br /> SOURCE OF DISCHARGE TANKS ONLYAPACITY MATERIAL CAUSE(S) <br /> D ❑ TANK LEAK 0 UNKNOWNS ) GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> Q ❑ PIPINGLEAK AGE YRS E;�-§TEEL ❑ CORROSION ❑ UNKNOWN <br /> 2 0 OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL OTHER <br /> Lu w CHECK O NENLY <br /> U ❑-'`UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r- CH=ONLY <br /> z <br /> w aNVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢F <br /> U N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ¢ ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> wu s <br /> h <br /> � 1 <br />