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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> emERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> E] YES 3?/NO REPORT BEEN FILED? <br /> E3 ❑ NO j:HEREBY:QERTIFY.THAT I AAF A DESIGNATED GOVERNMENT EMPLOYEE AND THAT!HAVf <br /> REPOR D THIS INFQRMATION T LOCAL{)FFICIALS PURSUANT TO SECT N 180.7 OF <br /> F 'ORT DATE 1TY , <br /> ASE y THE H AND S OODE <br /> �M M • D y Y - SIG D <br /> DATE'. <br /> NAME OF INDIVIDUAL FILI REP T PHONE SIGNATURE <br /> 5/6p3y2 <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p �OCAL AGENCY ❑ OTHER <br /> e ADDRESS C�Jj ��D�✓'^A ' �� ��+ "� <br /> , 10 <br /> 7 - • STREET �V•Y_CRr STATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> ❑ UNKNOWN <br /> .�. <br /> ADDRESS /1 /�/�� L/•{/��l R <br /> STATE ( IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> P6LZ-A Pu-[? ( ) <br /> a ADDRESS <br /> EETi (/Y✓^' �'� Crrvl--O�//��.J ./LJ• l�`1• q)UNTY 27P <br /> � � <br /> �I CR S STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER <br /> /�1Q FARM ❑ OTHER <br /> LOCAL AGE Y , �` AGENCY NAME CONTACTPERSON <br /> l ��W�-'�-�L./ (Z I PHONE) V ''rJ 2"o <br /> REGIONAL BOARD PHONE <br /> ) <br /> (1) NA E QUANTITY LOST(GALLONS) <br /> O <br /> NKNOWN <br /> (2) <br /> �, ❑ UNKNOWN <br /> _ <br /> DATE DISCOVERED HOW DISCOVERED E::] INVENTORY CONTROL F-1SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Pm M M / o �Dj Y r ❑ TANK TEST ❑ TANK REMOVAL ©OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Z UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> y, M M D D V r <br /> HAS DISCHAR E BEEN STOPPED 7 ❑ REPAIR TANK E] REPAIR PIP WG E:] CHANGE PROCEDURE <br /> ES ❑ NO IF YES,DATE v MI / mi yl i r ❑ OTHER Ti�- <br /> (� <br /> u SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> n i ❑ TANK LEAK UNKNOWN -3J7- GAL. Q FIBERGLASS ❑ OVERFILL O RUPTURESA1LURE <br /> ❑ PIPING LEAK AGE YRS t2rSTEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ©"GNKNOWN ❑ OTHER ❑ SPILL Q OTHER <br /> CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY a GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> N I ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) , E[2 EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> /,❑ TREATMENT AT HOOKUP <br /> /(HU) Q NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> u..��4.e �u`�-``�� ���-� tie i�•-Zu.�.c. �-C .,�,�7� <br /> &4 Ite <br /> w - <br /> HSC 05( <br />