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" UNDERGROUND STORAGE TAY UNAUTHORIZED RELEASE (LEAK)I 80�TAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ,FOR LOCALAGENCY',LISEONLY; <br /> ..: <br /> YES NO <br /> REPORT BEEN FLED? ❑YES ❑ NO 1 HEREBY'CERTIFY (HAT E AM 11 115IGilRTED GOVERNMENT <br /> - EMPLOYEE]4f3DTHAT 1 f(AVE': <br /> L-- ,REPORTEf3,THIS INFORMATION TO =AL:. FF PALS PU$Sl1A)fi TO:SECfK)N:25t807:DF <br /> REPORTOATE CASES <br /> 01m4.1 <br /> THE HEAL ANOSAFTY E <br /> fjJr <br /> 0M� 1 M1 a 4r� r SIGNED <br /> . ;.. <br /> SATE.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w RE;z:AGENCY <br /> G ❑ OWNER+OPERATOR ❑ REGI L BOARD COMPANY OR AGENCY NAME <br /> p ❑ OTHER <br /> a <br /> Q ADDRESS �Q Ii <br /> I CJD MTR€T / cmr, 70 f5 C�/'�' STATE <br /> NAME CONFACTPERSON PHONE <br /> 92 M �/ UNKNowN M T/�Y ��(✓�JS <br /> Qa ADDRESS <br /> tu <br /> -333 Y�les �`A- � - aA�44 57 Srg-ry a 5& <br /> FACILITY NAME(IF APPLICABLE) ' I OPERATOR PHONE I <br /> &✓e5 �4�js t l <br /> ADDRESS S v/1' d f� J��v I2j2 7 9 3 <br /> 1-77 <br /> 7 �l 17 L <br /> � L� STREET GIIY COk1NTY P <br /> wCROSSSTREET TYPE OF AREA COMMERCIAL F]INDUSTRIAL ❑RURAL PE OF BUSINESS ❑ RETAIL FUEL STATION <br /> 98 V v A ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> I Lu REGIONAL BOARD 9PHONE <br /> G V)e w 0 G/ t9I � 3�i a <br /> (I) NAME OUANTRYLOST(GALLO <br /> • V��it/G U C om U l�I UTMNOWN <br /> O (2) <br /> H ❑ UNKNOWN <br /> = <br /> DATE DISCOVERED Cf HOW DISCOVERED ❑ I ORY CONTROL SUBSURFACE MONITORWG ❑ NUISANCE CONDITIONS <br /> wV M �M D o 0 +v r E] TANK TEST: TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN / s METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u M o o r <br /> } UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK �CLCSEANK <br /> � r <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPNG ❑ CHANGE PROCEDURE <br /> a ❑ YES ❑ NO IF YES.DATE u� Mi of o r r ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLYrAPACITY MATERIAL CAUSE(S) <br /> ,�� ❑ TANKLEAK UNKNOWN 4�p GAL ElRGLASS ❑ OVERFILL ❑ RUPTURE/FALURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION NKNOWN <br /> ❑� OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu CHECK ONE ONLY <br /> U ❑ DETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F <br /> CH E ON'=ONLY <br /> z y <br /> Q a SITE INVESTIGATION IN PROGRESSEM) E:](DEFINNG EXTENT OF PROBLEM CLEANUP IN PROGRESS[:] SIGNEOOFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> v y ED NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS E] NO FUNDS AVAILABLE TO PROCEED L] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR OETAILS) <br /> 4 z ❑ CAP SITE(CD) ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PROOUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ Pr&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(FIS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) THER(01) <br /> S d i`G -5h,,117 '' *r //:3; I-V <br /> " �*j de X I c7rl I✓ Gt rt o(e r�ro u sti� 4(/Va,r�� d.:L s,fi r�g c f7f-,t✓,� <br /> z A'[/ �z —d - , fWA#1 eyQ-•-rf}- <br /> g �iviLL "� cc.�r to �erCv- . : ems GtGY� ti <br /> Gp TA �l i4�/o GSC 0-%w,Gt <br /> sc�c <br />