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UNDERGROUND STORAGE=TANK'UNAUTHORIZED BELE <br /> >< ASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY r,HAS STATE OFFICE;OF EMERGENCY siqiqms FOR LOCAL AGENCY.U$E:ONLY <br /> FILED 7. <br /> ❑ YES NO REPORT BEEN LYES NO 1HEREBY L'ERTIFY 71Af f AM A{�ES1GN1{TE[)G(SVEAN .:EMPL�YYE ANQ filfAf_I HAVE;. <br /> REPORT DATE REPORTED;TNIS INFORMATION<TO L4C, FICIAIS <br /> 7 <br /> CARP& THEN d ANT TQ SECTION 251801 OF <br /> aCr�S <br /> GODS �, /may) <br /> "'^ 51C9NE L <br /> NAME OF IN VIDUAL FILING REPORT <br /> PHONE - E <br /> �. sr <br /> SLI <br /> [z REPRESENTINGv <br /> ❑.OWNEFVOPERATOR- ❑ REGIONAL BOARD OR ENCYNAME <br /> o< <br /> O LOCAL AGENCY ❑ OTHER v <br /> a <br /> Ei <br /> cr ADDRESS ,/ <br /> /� a . <br /> �� ,C <br /> !3 NAME '; R STATE tm <br /> 1 ^ . CONTACT PERSON <br /> i .,�C '� ❑ UNKNOWN ~ " PHONE <br /> R, ADDRESSLu <br /> cc J I; - <br /> `��� <br /> 'STREET' <br /> oril � �n, <br /> F ITY NAME(IF APP ICABLE) SATE r <br /> (' OPERATOR PHONE <br /> ADORES - <br /> ���S � j L, X376 ]d <br /> w 9TiiEEt • - �er i <br /> W CR O5S STREET _ .� Com ' �' P 4! <br /> TYPE OF AREA COMMERCIAL INDUSTRIAL R RAL TYPE OF BUSINESS <br /> 0 ❑ ❑ RETAIL FUEL STATION - <br /> �� RESIDENTFAL Q OTHER <br /> FARM ❑OTHER; <br /> LOCAL AGENCY AGENCY NAME <br /> � ` CONTACT PERSON �. ;la�a tuREGIONAL BOARD � �CCL <br /> � � l-�i'eP6)3h1-s7 <br /> fel1 <br /> Lu o NAME QUANTITY LOST(GALLONS) # <br /> UNKNOWN <br /> ,/ ' o Jew, UNKNOWN <br /> z DATE DISCOVERED. WOW DISCOVERED INVENTORY CONTROL SUBS FACE MONITORING❑ NUISANCECONDITIONS <br /> �u pl ❑. TANKTEST ❑ TANKREMOVAL y OTHER <br /> w <br /> M p oo v �v <br /> DATE DISCHARGE BEGAN, METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) ` <br /> M M o o` v Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STpPPED 7,. . ❑ REPAIR TANK ❑ AEPAFR PIPING ❑ pHANGE PROCEDURE <br /> y <br /> S YES ❑ NO-IFYES.DATE M � �o SsS� OTHER <br /> Lu RCE OF DISCHARGE TANKS pNLYrCAPACITY ,a - MATERIAE <br /> JCMAUSE(S)❑ TANK LEAK ( UNKNOWNFIBERGLASS' QOVERFILL Q RUPTURE/FAILUREPIPINGLEAK AE - YRS ❑ STEEL - ❑ (:DRROSIpN UNKNOWN <br /> OTHERUNKNOWN ' ❑ OTHER ❑ SFIIL''.'a OTHER <br /> mL, CHECKONEONLY t <br /> u0. e. <br /> it ❑ UNDETERMINED ❑ Sp1L ONLY GROUNDWATER Y ❑ DRINKINGWATER- (CHECIC ONLY IF WATER WELLS'HAVE ACTUALLY BEEN AFFECTED) <br /> c9HONE ONLY . <br /> c SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢F <br /> "i NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ Np FUNDS AVAILABLE TO PROCEED' ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o CAP SITE(CD) . .. 14 <br /> ❑ ❑ EXCAVATES DISPOSE(ED) ,❑ REMOVE FREE PRODUCT.(FP),I ❑ ENHANCED910 DEGRADATION(1T) <br /> 2 cd ❑ CONTAINMENT BARRIER(CB) EXCAVATE 6 TREAT(ET) rg ❑.:PUMP 6 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ❑ TREATMFNTATFIODKUP(HU) O NO ACTIONREOUIRED;(NA) <br /> OTHER(OT) <br /> _ HSC05(4A37) <br /> 7 <br />