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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED? )HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNMENT EMPL64E ANO THAT I HAVE <br /> 0 YES � ❑YES ❑ No REPOR7E6 THIS:INFORMATION;TO LOCAL OFFICIALS PURSUANT TQ SECTION 251BQ7 OF <br /> THE HEALTH SAFTY CODE :: <br /> REPORTDATE CASE# <br /> I M0o U Y v SIGNED. GATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI NATURE <br /> o REPRESENT G ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY DR AGENCY NAM <br /> o ❑ LOCAL AGENCY ® OTHER ;I R�/1JSI T /S TtS�I C T .S70G/c"ON <br /> ADDRESS 7?C�✓ <br /> STREET S CITY STATE ZIP <br /> NAME CONTACT PERSON PHONE I <br /> In Sr ❑ UNKNOWN • �/' �{Ji1TG 00/ <br /> z� JY ST /G <br /> S a ADDRESS r / <br /> Q x s�G • y�/VLJSIJ x..11 OG K`�)v �•// ��c'�nj STATE ' ZIP E <br /> Lu //�� <br /> STREET CffY <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PFIOI IE <br /> S ToGttrav /,QAv ;r <br /> ADDRESS <br /> 1 S �tITTY P <br /> Y �/533 "Z • Nrr l <br /> CROSS STREET TYPE OF AREA COMMER61AL INDUSTRIAL❑RURAL TYPE OF BUSINESS F-1RE-FAILFUEL STATION ) <br /> 0� �� �RESIDENTIAL Q OTHER E] FARM 0 OTHER LS <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w REGIONAL BOARD PHONE <br /> IL <br /> {t) NAME QUANTITY LOST(GALLONS) <br /> W <br /> i� � UNKNOWN <br /> .I <br /> (2) <br /> ❑ UNKNOWN <br /> ►- DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> IM Ou a`b dD �v 9 Y � TANK TEST ❑ TANK REMOVAL ❑ OTHER I <br /> DATE DISCHARGE BEGANMETHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u UNKNOWN ❑ REMOVE CONTENTS, ❑ REPLACE TANK ❑ 1CLOSE TANK <br /> HAS DI ARGE BEEN STOPPED? Y ❑ REPAIR TANK E] REPAIR PIPING ❑ ,JCHANGE PROCEDURE <br /> 7YIj <br /> p ES ❑ NO IFYES,DATEY OTHER <br /> T,1 M O 0 Y <br /> Lu SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) i <br /> 3 ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFAILURE <br /> PIPING LEAK AGE �{-J -YRS I STEEL ❑ CORROSION UNKNOWN <br /> tv <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER ' <br /> W w CHECKONEONLY <br /> t4 ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> cc .SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑i CLEANUP IN PROGRESSE] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) V�1 <br /> V w ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES I <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> r-1 CAP SITE(CD) ❑ EXCAVATE 3 DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION{IT) <br /> M!i ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> c <br /> E] TREATMENT AT HOOKUP(HU) NO ACTION REOW RED(NA) E] OTHER(01) <br /> (� Slr�l Gts5 �xs1�% Iy� . /� lie l-E� �d/.•-ALT rG GAe��ray <br /> w y • / 1 <br /> Lv /�J�! T` �v-/�'1lt.i�i/i!.s fi�v/ �•2 milia/ C� �� i <br /> . .. HSC OSi�87I <br /> I'e � <br /> v <br />