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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED 7 r�-,/ }HEREBY':CERTIFY-THAT E AM- OESiGNy1TED GOYERNMENi MPLOYEE:ANO THAT t HAVI ; <br /> [] YES YES I REPOWD THIS.INFbRMATION:TO 10CAR OFF1C{A{S PURSURHT 70 SEGTtON 251807 OF <br /> :THE HEAL AND 000E f <br /> RE/POR70A\TE/,)( �jy CASEII l / fi �tIZ <br /> MI `rM V 6 ?y y -.N .. ..♦ATE <br /> PHONE SIGNATURE <br /> NAME OF INDNIDUAL FILING REPORT <br /> 1) ���� G <br /> ` `cam eSC <br /> m ❑ ❑ REGIONAL BOARD �MPANY O AGENCY N f <br /> REPRESS TNG OWNEWOPERATOR �(1' <br /> a p ` H I <br /> OLu LOCAL AGENCY ❑ OTHER ` <br /> ApOR5O1 o <br /> (JJ� CITY STATE 1" 21P <br /> sTREET PHONE a; <br /> NAME r CONTACT PERSON <br /> N8- P, D( ! ❑ UNKNOWN /J c �t /�� <br /> a <br /> ADDRESS�/- G-� 3(O o �a a'1 c lt.�,C.v:G ev�1- C� / T 5P <br /> E� 1". P I <br /> � STATE <br /> STREET _ FELONS <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> ADDRESS r �CCVN <br /> GIC-��� <br /> f TY <br /> STREerry <br /> TYPE OF BUSINESS RETAIL FUEL STATION <br /> CROSS STREET TYPE OF AREA COMMERCIAL❑INDUSTRIAL❑'RURAL <br /> RESIDENTIAL ,❑OTHER FARM OTHER k <br /> UJO,5 f L4'— C7] <br /> PHONE <br /> LnGALAGENCY AGENCY NAME CO ACiPERSON <br /> r � �'tu <br /> RD v <br /> � �C U IONAL Ali uJ C r3 t <br /> QUANTITY LOST(GALLONS) <br /> (') o NAME ': �NKNowN I <br /> w <br /> 6',. ❑ UNKNOWN <br /> rSUBSURFACE MONITORING CONDITIONS <br /> z DATE DISCOVERED: HOW DISCO RED INVENTORY CONTROL ❑ <br /> 9 ((((�'''��/ TANK TEST ❑ .TANK REMOVAL ❑ <br /> OTHER <br /> o o - �v METHOD USED TO STOP OISCHAAGE(CHECK ALL THAT APPLY) <br /> DATE DISCHARGE BEGAN <br /> KNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑,CLOSE TANK <br /> M M v y ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> HAS DISCHARGE BEEN PED 7 t <br /> QQ ❑ OTHER v. <br /> i ❑ YES NO IF YE5,DATE M M n n r v. <br /> TANKS ONLYICAPACl7Y MATERIAL CAUSE{S} } <br /> y SOURCEOFDISCHARGE GAL ❑ FIBERGLASS E] OVERFILL ❑ RUPTUREIVAILURE <br /> TANK LEUNKNOWN <br /> F-1AK YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> 9 AGE <br /> cc ❑ PIPING LEAK ❑ UNKNOWN ❑ OTHER ❑ SPILT ❑ OTHER <br /> ❑ OTHER <br /> uj w CHECK ONE ONLY <br /> v m ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) 4 <br /> CHECK ONE <br /> s 4 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF pROBLEMy '❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY} z <br /> c N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION{S}(SEE BACK FOR DETAILS) ❑ ENHANCED BIO DEGRADATION(IT) i <br /> 4* ❑ CAP SITE(CD) ❑ EXCAVATE b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP} 3r <br /> w EXCAVATE b TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT} ❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER{OB} ❑ � <br /> ❑ TREATMENT AT HOOIOJP(FW} ❑ NO ACTION REQUIRED(NA) ❑ OTHER(0T) ` C� <br /> ca <br /> assess <br /> „EGOS N/' <br />