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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGqNCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> � <br /> —/ REPORT BEEN FILED? 1 HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT 1 HAVE <br /> t� <br /> E] YES NO YES 0 NO REPORTED THIS INFORMATION TO IOCAL OFFICIALS PURSUANT TO.-SECTION 25180.7 OF <br /> REPORT DATE CASE* THE:HEALTH D <br /> 1a <br /> MI M rI v WUNED Tll E -.: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> > I (20q) 6S—3 y0 d <br /> REPRE NTING OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME (�L <br /> ¢O �LOCAI AGENCY OTHER .7�ti (' �{/N /v j(!7 {C ff t"�1 A Seal,C�� <br /> a <br /> ADDRESS <br /> 160 ` 0'PJ STREET S`OC"�� CITY c STATE © R <br /> NAME CONTACT PERSON PHONE ��j rr <br /> y UNKNOWN S ) 7L` �00 <br /> 4a ADDRESS <br /> cc 2�X, //y ,p �J <br /> P. 1'�" I STREET lv T/J CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) - OPERATOR PHONE <br /> 6 ,a( REAtielft Ma f 6m U I (CC90 2•-(%00 <br /> !j ADDRESS <br /> SoA� <br /> J STREET cuiti 95-) <br /> COUNTY ZIP <br /> CROSS STREET TYPE OF AREA O COMMERCIAL INDUSTRIAL O RURAL TYPE OF BUSINES Q RETAIL FUEL STATION <br /> =RESIDENTIAL OTHER FARM OTHER <br /> ' LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> y /� 3yyl' <br /> W OQ UJN lf,L<, Ou 6 c >°t,M A Ct.✓ (74�/) y�.,- <br /> w w REGIONAL BOARD PHONE( ) <br /> CL <br /> (1) NAME QUANTITY LOST(;ruNKNOWN <br /> S) <br /> U j�N� <br /> (2) (�J <br /> h [�/UNKNOWN <br /> DATE DISCOVERED l/ HOW DISCOVERED a INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> i <br /> w ( M DI - D v y TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN REMOVE CONTENTS REPLACE TANK LOSE TANK <br /> W M M D D Y Y <br /> HAS DI HA <br /> RGE BEEN STOPPED? �f n REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> o YES = NO IF YES.DATE /MI Z�,I f.oI O oI I v y OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) 1_ <br /> q i TANK LEAK UNKNOWN CX)0 GAL. Q FIBERGLASS = OVERFILL J&TURE/FAtLURE <br /> PIPING LEAK AGE�l�YRS STEEL = CORROSION UNKNOWN <br /> O OTHER UNKNOWN OTHER a SPILL Q OTHER <br /> Lu CHECK ONE ONLY <br /> toa <br /> v UNDETERMINED O SOIL ONLY GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> z <br /> ul <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) = CLEANUP IN PROGRESS= SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U y 0 NO ACTION TAKEN = POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> � <br /> REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT)z O CAP SITE(CD) � EXCAVATE�DISPOSE(ED) � / <br /> F3 0 <br /> w$1 ONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP b TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Q O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA) Q OTHER(OT) <br /> G��P_ >�-7� ✓�// - /" i//% 'fa c ,P{ rrrlNP die /✓c�r�re c��-r� Irtif` c <br /> W <br /> �vv�Glrl�.vt�}/CIU fly /'AcT!!JT`Qr� �+� jP cz��9rYY"dC /�'�`'z'f�T2'f� s��/�•�/ <br /> / d MSC O5(MH7) <br /> k <br />