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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGE SERVICES FOR LOCALAGENCY USE ONtY <br /> YES NO REPORT BEEN FILED? L—,/YES Np (HEREBY.,:CERTIFY>THAT t:AM A DESK MATED GOVERNMEM:EMPLOYEE ANDTHgT l HAVE: <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT.TO,SECTION 25180.7 OF <br /> REPORT DATE CASE s THE HEALTH ANJ�SAETYIOOD�E <br /> 0 M1 j M d 5-D 9,yll r SIGNED ,::: . DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESE ING 0 OWNERIOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 2 /� motif CiJ�� <br /> p LOCAL AGENCY [:] OTHER <br /> a <br /> ADDRESS <br /> ✓ccs LL -S�c,c <br /> STFEET CITY STATE ZIP <br /> w NAME CONTACTPERSON PHONE <br /> J <br /> cobo -7r- -5;2/min ❑ UNKNOWN <br /> F ADDRESS <br /> IIIo�4l�'/ r-i�'p c�7� /n���s� qs-?su <br /> `9TREEI� CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS -S922107-R).?Q.uM <-a,W .� //STREET CITY /+.LJ/J LG COUNTY P <br /> CROSS STREET TYPE OF AREA COMMERCIAL Q INOUSTRWL 0 RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> » A- I 0 RESIDENTIAL =OTHER a FARM OTHER <br /> LOCA AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> W J o� .a..i� -/!i rPrvr'e C xei (A ) 4/1c4-S' <br /> w w REGIONAL BOARD PHONE <br /> a. ( ) <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> W <br /> 77y A-,---a- / _ UNKNOWN <br /> 0 <br /> y <br /> 82/?l�/� ' UNKNOWN <br /> Z DATE DISCOVERED ¢Q� Gj HOW DISCOVERED a I NTORY CONTROL SUBSURFACE MONITORINGa NUISANCE CONDITIONS <br /> ! v 0 Y TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> >W [:2/UNKNOWN a REMOVE CONTENTS = REPLACE TANK F CLOSE TANK <br /> � <br /> HM M D D V Y AS DISCHARGE BEEN STOPPED? REPAIR TANK � <br /> REPAIR PIPING CHANGE PROCEDURE <br /> D D Y v OTHER <br /> p a YES 0 NO IF YES.DATE MI MI <br /> Lu <br /> SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> U a TANK LEAK UNKNOWN S'(o GAL FIPI:RGLASS Q OVERFILL RUPTURE/FAILURE <br /> Q ❑ PIPING LEAK [ErAGE YRS STEEL a CORROSION ��NKNOWN <br /> 8 = OTHER ERtUNKNOWN 0 OTHER a SPILL = OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED a SOIL ONLY a GROUNDWATER a DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z N <br /> Lu a a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS= SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢F <br /> Q�+ 0 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 /> z CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> o <br /> LLJ c~� CONTAINMENT BARRIER(CB) a EXCAVATE&TREAT(ET) PUMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> a TREATMENT AT HOOKUP(HU) Q NO ACTION REQUIRED(NA) OTHER(OT) / <br /> �n �Ur��ier Sr /P LtSSCSS/�Q Ge 1i l/ �e r�GCESSCec;. f0 Ote�Am �•+r f�CP rcc. Ccl <br /> z <br /> czn eX k'rt i o{` Coil fci/ir/nG 1�tOii G!-J r!G t/hJL/ G7r t �' 10 r/ <br /> HSC os(4ffn <br />