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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 T HEREBY CERTIFY THAT A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES �NO ❑YES �NO REPORTED TH A T0. OFFICIALS PURSUANT T�O�SECTION <br /> Q251807 OF <br /> REPORTDATE CASES THE HEAL S Y r ' ,. <br /> M / M O 0 Y g/y - DATE <br /> NAME OF INDIVIDUAL FILING REPORT P qE SIGNATURE <br /> 0 REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AIIGENCVN � -� l5 <br /> ¢o ®'COCAL AGENCY ❑ OTHER4�,VQ (Ci✓\ J <br /> 0 <br /> ADDRESS <br /> PU 'Loo9 ss� <br /> STREET � 3IATE � ZN <br /> NAME CO/NTT�ACCTPERSO <br /> PHONE <br /> LA- <br /> , LlNE-)R ❑ UNKNOWN <br /> DADDRESS <br /> Y0� vv, <br /> o <br /> /^�V BTREU CRYr SPATE zip <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> hh �{// G <br /> i (�7 /ea6 <br /> OF ADDRES <br /> x �a l er foo orryr <br /> yCROSSSTREET TYPE OF AREA COMMERCIAL®INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> 7Y 5`� ❑RESIDENTIAL ❑OTHER ❑ FARM ®"OTHER <br /> LOCALAGENCY AGENCY NAME OONTACTPERSON PHONE <br /> yeo, ds � , ill (�� z3 <br /> ww J o uT <br /> w REGIONAL BOA RD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> O p <br /> 67 <br /> t/_ � // <br /> �UNKNONM <br /> �0 T l <br /> o (2) <br /> ❑ UNKNOWN <br /> DATEDISCOVERED / HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> DM M D �D 2yi Y ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> �! UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK ®' CLOSE TANK <br /> 5p� HAS DISCHARGE BEEN STOPPED 7 y ❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGEPROCEDURE <br /> O "®,YES ❑ NO IFYES.DATE al 6 M -2-D la D 7,1 (o y ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLVA:APACI7Y s� MATERIAL CAUSES) <br /> ❑ TANKLEAK UNKNOWN OOD �' ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> c ❑ PIPINGLEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ww CHECKONEONLY <br /> �it ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F, CHECK ONE ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) E:] CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARI) <br /> ow ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS E] NO FUNDS AVAILABLE TO PROCEED E] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION($)(SEE BACK FOR DETAILS) <br /> ag ❑ CAPSITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> i ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(EID ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TRFATM�E/NTS/A'T/HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> i <br /> �/ HSCW4W) <br />