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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGE U ONLY REPORT BEEN FLED 7 ❑ YES NO [:DYES (� NO 1 HEREBY CERT :7 (: ,A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE REPORTED:TH MA TO LOCAL OFFICIALS PURSUANT TO SECTION'251ft?OF REPORT DATE CASE# THE HEALTH yY �M �M 8-yl ir y ! V SKINNED .>: DATE. NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE K�C REPRESENTING OWNER/OPERATOR' ❑ REGIONAL BOARD COMPANYORAGENCY NAME LOCALAGENCY.� OTHER S..I �� vi►� Lo•�I N ecl�� D� I z [ATIRESS AS�v STREET p,,, NAME STATE 21P T 'T UNKNOWN ADDRESS CONTACTPERSON PHONE 7 -LA,c- 1 SZ"JZ-6 J ¢ ❑ / � a l C ` ST (� REET J�C � ` Ury FACILITY NAME(IF APPLICABLE) 71P Z-9) -T OPERATOR t� PHONE ^.� off.. To�. .�. lti IC c� Yo.✓r.�e✓ ( moi) `iS2-326 o ADDRESS Flo N STREET y TY US CROSS STREET TYPE OF AREA COMMERCIAL INDTRIAL RURAL PE OF BUSINESS P � ❑ O o.� ❑ ❑ RETAIL FUEL STATION RESIDENTIAL ❑OTHER ❑ FARM OTIiER LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE P,4 WJam,�,. 04 .;��.. LDL.-. w REGIONAL BOARD � ��.�✓c� ��\? PHONE cn w o NAME I OUANTITY LOST(GALLONS) — e`C✓D1 �.v� �vo c.�✓7a� S _ UNKNOWN UNKNOWN z DATE DISCOVERED HOW DISCOVERED w ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 2T- &-y y ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) } UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK cc M M D D V y ?Q� HAS DISCHARGE BEEN STOPPED 7 EIRE PAIR TANK REPAIR PIPING CHANGE PROCEDURE p YES ❑ NO IF YES,DATE ` M� M SDI DI �Yj r y ❑ OTHER y SOURCE OF DISCHARGE TANKS ON Y,CAPACITY MATERIAL CAUSE(S) Oma ( o00 ❑ TANK LEAK � UNKNOWN 1 rS�3I1L. V ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE ¢ ❑ PIPING LEAK AGE_____ YRS ❑ STEELElCORROSION UNKNOWN OTHER lK UNKNOWN VT OTHER L�+11� 0-1, % ❑ SPILL ❑ OTHER w CHECK ONE ONLY v ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) r CHECK ONE ONLY z� cc cr ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) U`� ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) o ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) uJ ❑ CONTAINMENT BARRIER(CB) EXCAVATE i TREAT(ET) PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) J`)� w 8 HSC 05(4S7)