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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENdY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES NO YES NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE# THE HEALTH AND SAFfY CODE <br /> MI M - +I -I v !• Y SIGNED < DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> co <br /> } ( ) <br /> LU <br /> REPRESENTING F–] OWNERIOPERATOR F--] REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc <br /> O [?r'LOCALAGENCY ❑ OTHER <br /> a <br /> cc <br /> w ADDRESS <br /> STREET CITY STATE ZIP <br /> W NAME / CONTACT PERSON PHONE <br /> co <br /> III` ❑ <br /> Fn f t T_t 'Y` „�A{. UNKNOWN <br /> Ri ADDRESSrn <br /> ¢ <br /> STREET CRV STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> w ATAEET CITY COUNTY ZIP <br /> ~ CROSS STREET TYPE OF AREA TYPE OF BUSINESS <br /> rn COMMERCIAL INDUSTRIAL RURAL RETAIL FUEL STATION <br /> RESIDENTIAL OTHER FARM "OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> LUN <br /> wLuREGIONAL BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> ZV O i�yy� n ,': .:' t'/.. ��ii J''1.,. ❑"UNKNOWN <br /> cn a <br /> UNKNOWN <br /> z DATE DISCOVERED .�'� r HOIWWDISCgWRED INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w M'LLIy M D I o �� v y LJ TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> > UNKNOWN REMOVE CONTENTS REPLACE TANK ❑ CLOSE TANK <br /> cc W <br /> M M D D Y Y <br /> HAS DISCHARGE BEEN TOPPED? E❑lREPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> I <br /> p ❑ YES � NO IF YES,DATE M M D o v Y Fa "THER - <br /> y SOURCE OF DISCHARGE r' TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> D TANK LEAK E�fUNKNOWN GAL, ❑ FIBERGLASS OVERFILL ❑ RUPTURE FAILURE <br /> ❑ PIPING LEAK AGE a— YRS STEEL ❑ CORROSION � UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER SPILL ❑ OTHER <br /> w w CHECK ON-Fx<fNLY <br /> ❑I UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE`ONLY <br /> ZN <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F—] CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> cc <br /> U U) ❑ 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 /> w� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> ky, �r R ee1""w <br />