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0 0 0-a & I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> T V <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY S s F08 LOCALAGENCY USE ONLY:;;.:...:.::•:......:.... :;::.;:'> :.;>.<>:::.;;::.::•:.;:.;:.;::.>:.;:::.:.;:<.;':.;:.;::, <br /> REPORT BEEN FILED9 j;HEREBYaRTIFY:THAT I:AM:q;pESIGN4t 0.'GOVm ' E EluifyC�JYE`i``'ANG) fWAt:.I;HAVE. <br /> ❑ YES NO ❑YES <br /> NO REPORTED THIS 1NEORMATION,TO;LAC F(CfALB. .SUANT:TQ':5ECTION.251A0,7';OF: <br /> THE HEAL <br /> .. :: <br /> REPORT DATE CASES <br /> Iyl ................. <br /> NAME OF tIWJVIDUAL FILING REPORT PHONE 51 E <br /> 2�c�z <br /> a REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONALBOARD OR AGENCYNAME � <br /> LOCALAGENCY ❑ OTHER <br /> a <br /> ADDRESS <br /> /d of S?REET /'V� / /�-1� 1 <br /> CRY � STATE W <br /> NAME /� CONTACTPERSON PHONE <br /> U) \ T l I - c,-e,2 ❑ UNKNOWN - ) <br /> 9 a ADDRESS <br /> LLI <br /> ! STREET /1 -#-l/a) CRY �./'� � LJ STATE rp <br /> FA ITYNAME(IFAPP (CABLE) OPERATOR jPHONE <br /> � ri' 4( Sv )I <br /> ADDRES ////1 1 /� \ r y <br /> 69 <br /> ! / STREET ll-� { �� m. / FC <br /> y COUNTY ZIP <br /> CROSS STREET TYPE OF AREA COMMERCIAL❑INDUSTRIAL ❑R RAL TYPE OF BUSINESS P�l RETAIL FUEL STATION <br /> (Jr [:]RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON ��PHO <br /> w REGIONAL BOARD 1 PHONE <br /> (A NAME QUANTITY LOST(GALLONS) <br /> Lu <br /> C UNKNOWN <br /> m 0 <br /> /0 / - O 1` / J Cc�� UNKNOWN <br /> DATE DISCOVERED (�, HOW DISCOVERED <br /> = ❑ INVENTORY CONTROL SU FACE MONITORING ❑ NUISANCE CONDITIONS <br /> 6M opo ©o v vv ❑ TANK TEST ❑ TANK REMOVAL L OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o v Y UNKNOWN ❑ REMOVE PL <br /> CONTENTS ❑ REACE TANK ❑ CLOSE TANK <br /> }> HAS DISCHARGE BEEN STOPPED? {_ ❑ REPAIR TANK. ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> Q YES ❑ NO .IF YES,DATE M � `-' o "v�Y OTHER <br /> RCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK � UNKNOWN GAL. ❑J FIBERGLASS ❑ OVERFILL ❑ RUPTUREiFAILURE <br /> C� ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> d ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHE ONE ONLY <br /> zN <br /> cr i SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 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 /> 4 ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP), ❑ ENHANCED BIO DEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ .PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> rf e� ,117LlrS s' v7 rrf v, <br /> 74, <br /> e x1-44 <br /> 8 qS rig L 24M62L <br /> HSC 05(447) <br />