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i <br /> )_ 9L/) 7- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV? FQRL(IT)CALAGgNCYIJ$EONLY I: <br /> O YES � REPORT BEEN FULED? DYES � 1 HEREBY aRTIFY THAT I AM A DESIGNATED GDVEpNMENT EMPIDYEE AND THAT A HAVE.; <br /> LJ L14 NM REPORT D THIS INFORMATION TO =AL OFFICVLS PUNSUANT TD SECTIGN 251009 OF: <br /> REPORT DATE CASEi - THEN TRR ANO SAFfY <br /> �f t <br /> M . / DI <br /> y ED - W <br /> NAME INDIVIDUAL FLLING REPORT PHONE SIG RE <br /> m <br /> REPRESENTING ,,OWNERtOPERATOR a REGIONAL BOARD COM PANYORAGENCYNAME <br /> g LOCAL AGENCY OTHER <br /> a d <br /> ADDRESS <br /> srnEEr J <br /> NAME CONTACT PERSONON WATE alpPHONE <br /> UNKNOWN <br /> ADDRESS <br /> y ADDRESS <br /> " C <br /> C <br />. BTREEI. ✓\ FYC'M /j-WATE. I <br /> 'CT/ p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR - PHONE <br /> 41_7 1-32- <br /> ADDRESS <br /> 3555 'Lo " - PFMkq LPr )E SccK�� Sii+��oAgo)N 9520 E <br /> yCROSS STREET -' TYPE OF AREA OCOMMERCIAL O INDUSTRIALRURAL TYPE OF BUSINESS <br /> O"RETAIL FUEL STATION <br /> I "lI�"�.(�L�1�S ✓1`��I.� MRES IDENTIAL O OTHER O FARME::] OTHER <br /> LOCALAGENCV ., AGENCY NAME CONTACT PERSON PHONE <br /> w K b <br /> uJ w REGIONAL BOARD - PHONE <br /> U) 01B <br /> NAME OUANNTRY LOST(GALLONS) <br /> L/. L T- C )u 9Cn('rAL. © UNKNOWN <br /> m <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOWDISCOVERED O INVENTORY CONTROL Q SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> w } <br /> ZD ,Q TANK TEST O TANK REMOVAL OTHER arc , <br /> .I u D v (� ., <br /> S DATE DISCHARGE BEGAN - METHOD USED TO STOP DISCHARGE(CHECK ALLTHATAPPLY) <br /> UNKNOWN F-1 REMOVECONTENTS O REPLACE TANK 0 CLOSE TANK <br /> pHAS DISCHARGE BEEN STOPPED? REPAIRTANK E] REPAIR PIPING CHANGE PROCEDURE <br /> p YES O NO FYES,DATE'' M H 7 96 �r y OTHER -ii <br /> H SOURCE OF DISCHARGE TANKS ONLV.CAPACITY MATERIAL CAUSE(S) <br /> q O TANKLEAK O UNKNOWN - C �GAL. FIBERGLASS O OVERFILL ORUPTUREFAILURE VO) <br /> w �PIPINGLEAK - AGE� YRS Q STEEL O CORROSION 0 UNKNOWN <br /> OTHEfl UNKNOWN O OTHER <br /> Q SPILL 0 OTHER <br /> ywy� CHECK ONE ONLY <br /> B� Q UNDETERMINED 12 SOILONLY O GROUNDWATER 0 DRINKING WATER. (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) i ' <br /> F CHECK ONE ONLY <br /> m <br /> Q 0 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) E-1 CLEANUP IN PROGRESS Q SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> c3`A Q NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE RACK FOR DETAILS) - <br /> o f-7 CAP SITE(CD) -O EXCAVATE&DISPOSE(ED) h REMOVE FREE PRODUCT(FP) ENHANCEDBIODEGRADATION(IT) <br /> ¢c� Q CONTAINMENT BARRIER IDS) O EXCAVATE B TREAT(ET) E:] PUMP&TREAT GROUNDWATER(GT) a REPLACE SUPPLY IRS) E <br /> TR EATMENTATHOOKUP(HU)' O NO ACTION REQUIRED INA) E] OTHER PT) � <br /> { l u`t'her 5 rfJ f eSSrn c n�t''/ W I I I V req,u I f CL( CIO de_t e.�Y�A t m C file Gtl K_ <br /> C-`PjX�k'o� Ctriti`�i V1tt �Y'to7l � I-,9n cl kJll t l� �G'�J�c(�r.IC <br /> _I I <br /> I <br /> I <br /> I <br />