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' 4] <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES '-FOR LGCALAGENGY USE 0NL. � <br /> Q YES NO REPORT BEEN FILED Z Q YES Q NO REEPORTED T#iIS NFORMATI0NAT0 S)C,NR t7FFtCW S:PCIYEFIPURSI]ANT 7O SECT[ON 2x1801 f1F <br /> REPORT DATE CASE o „THE HEALIM ANI7 SIiFiY ODDS <br /> DM` V M v pl `y / y SIGNED G0.TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> o REPRESENTING COMPANY OR AGENCY NAME <br /> � Q OWNERIOPERATOR Q REGIONAL BOARD <br /> dLOCAL AGENCY Q OTHER � I/(J/U 6* S F t4 J <br /> w ADDRESSa _ t VAIJ!09 7 <br /> cnly •`] 'rz�a/ <br /> NAME �I c CONTACT PERSON PHONE 'l <br /> Z¢ V J c�UNKNOWN M^ �S <br /> L9 a ADDRESS {��+ J�/} /�.i'(�y-{ 3/Z , CA--!?,) <br /> /� ` �}yA <br /> It-z5- E'f"�..� 0 S ll C" I 3fATE KT ,) ll�p 2— <br /> FACILITY <br /> FACILITY NAME(IF APPLICABLE) GQ U� OPERAAR PHONE <br /> z ) <br /> o <br /> ADDRESS <br /> W <br /> S779CfCT�'' cpw,ry T J -� fl <br /> CROSSSTREET � TYPE OF AREA Q COMMERCIAL 0 INDUSTRIAL Q RURAL TYPEOFBUSINESS Q RETAIL FUEL STATION j <br /> )` h Q RESIDENTIAL Q OTHER Q FARM Q OTHER <br /> i LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> v�is �4 1) <br /> w� S. <br /> w REGIONAL BOARD PHONE <br /> 2 c ✓ 12- C-6fM) 31# 53 <br /> Go (I} NAME QUANTITY LOST{GALLONS) <br /> Q UNKNOWN <br /> i� cn Q UNKNOWN <br /> j z DATE DISCOVERED G� HOW DISCOVEREO Q INVENTORY CONTROL Q SUBSURFACE MQNITORINGQ NUISANCE CONDITIONS <br /> Q TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> uu o o y y UNKNOWN Q REMOVE CONTENTS Q REPLACE TANK Q CLOSE TANK <br /> Lu <br /> HAS DISCHARGE BEEN STOPPED 7 Q REPAIR TANK Q REPAIR PIPING Q CHANGE PROCEDURE <br /> I p Q YES Q NO IFYES,DATE M 0 D y y Q OTHER <br /> f Lu N SOURCE OF DISCHARGE TANKS ONL ITY MATERIAL CAUSE(S) <br /> 4 Q TANK LEAK X UNKNOWN GAL, Q FIBERGLASS Q OVERFILL Q RUPTURE/FAILURE <br /> Q PIPING LEAK AGE YRS STEEL Q CORROSION Q UNKNOWN <br /> f Q OTHER 19 UNKNOWN Q OTHER Q SPILL Q OTHER <br /> LU w CHECK ONE ONLY <br /> v UNDETERMINED Q SOIL ONLY Q GROUNDWATER Q DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z y <br /> Cc s Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) Q CLEANUP IN PROGRESS Q SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY)cc <br /> 1 <br /> vH Q NO ACTION TAKEN Q POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES i <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) t <br /> I <br /> z Q CAP SITE(CD) Q EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) Q ENHANCI=D 8K)DEGRADATION(IT) <br /> 2 Q CONTAINMENT BARRIER(CB) Q EXCAVATE&TREAT(ET) Q PUMP&TREAT GROUNDWATER(GT) Q REPLACE SUPPLY(RS) <br /> I Q TREATMENT AT HOOKUP(HU) Q NO ACTION REQUIRED(NA) Q OTHER(01) eC'� <br /> W n,, <br /> m u I,ee r -� ,deme rv,1 i h - v.�- e x� 4- o j <br /> 1 804c..{, <br /> C wA-M n1t1 <br /> rlsc (da�1 ; <br /> 4 <br />