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6f 4t <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY.USE ONLY <br /> YES lvrNO REPORT BEEN FILED Z a YES Q NO D THAT-1 HAVE <br /> REPORTED.THIS NFORMATION TO.SLOCAI Of IC(ALS URSUANT TO:: ETIIO251.801 OF <br /> THE HEALTH AND .......SAFTY CODE <br /> REPORT DATE CASE i arses <br /> DMI 5.1 V d ol 71 1 v SIGNED': DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> \v s �,�; ri P ) 68-3 <br /> w REPRESENTING OWNERIOPERATOR F REGIO AL 130ARD COMPANY OR AGENCY NAME <br /> pLOCALAGENCY OTHER <br /> a <br /> ¢ ADDRESS <br /> v I S'FR2ET �zv(3 CITY r.J O STATE <br /> J NAME 1e-\lGf o M ) CONTACTPERSON PHONE <br /> G2� �� a UNKNOWN d Ne- 7t'fr/N q b Z <br /> Qa ADDRESS <br /> w q -7 q 9' 03 <br /> ¢ <br /> 6Ra� <br /> STREET CRI' I STATE n <br /> FACILITY NAME(IK-�-�`CABLE) � �-�� 1� OPERATOR �PHONE _� <br /> ADDRESS <br /> EETcrry Pw COUS NTY <br /> y CROSS STREET TYPE OF AREA 0 COMMERCIAL Q INDUSTRIAL 0 RURAL OF BUSINESS 0 RETAIL FUEL STATION <br /> VArP I'CCU AD Q RESIDENTIAL Q OTHER Q FARM Q OTHER <br /> LOCAL AGENCY s �. u«yE CovAIT CONTACTPERSON PHONE <br /> w� !" ccs cu, ) �t=3�Lo <br /> W <br /> REGIONAL BOARD PHONE <br /> (�) /NAME QUANTITY LOST(GALLONS) <br /> ��r•0 I u GF1��a1-�► UNKNOWN <br /> (2) <br /> y- UNKNOWN <br /> Z DAhTE DISCOVERED HOW DISCOVERED � INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS , <br /> "M 16.10 D c• Y D TANK TEST TANK REMOVAL a OTHER ISI a LQ VQ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> } 0 UNKNOWN Q REMOVE CONTENTS a REPLACE TANK F--j CLOSE TANK <br /> ¢ M M D D v Y <br /> w <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p YES O NO IFYES.DATE M M) .1 .1 YI v OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK Pq UNKNOWN .1101 ,000 GAL. F7 FIBERGLASS Q OVERFILL O RUPTURE/FAILURE <br /> PIPING LEAK AGE _YRS J STEEL CORROSION UNKNOWN <br /> OTHER a UNKNOWN Q OTHER =SPILL a OTHR <br /> w w CHECK ONE ONLY <br /> vCL <br /> 0 UNDETERMINED a SOIL ONLY Q GROUNDWATER 0 DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> zN <br /> ¢a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS E::] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U h Q cr <br /> 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 BACK FOR DETAILS) <br /> ozz ED CAP SITE(CD) Q EXCAVATE&DISPOSE(ED) a REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> m � CONTAINMENT BARRIER(CB) EXCAVATE 8 TREAT(ET) PUMP 5 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTION REOUIRED(NA) Q OTHER(OT) <br /> F �o i L ✓^z s (,4 l'f5 ►'?z�!�' Cp ni -f--r'o nq 1;::)7ea/4 / <br /> 4 <br /> rep4-eQ-ele-- difPs dSam)o // •/!;,— <br /> 7/-4-M <br /> kj(i4ed fn G <br /> HSC OS(ME7) <br />