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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESAO <br /> ❑YES � O REPORT BEEN FLED 7 ❑YES ❑ NO 1:HERESY:C�RTIFY THAT I AM:A OSKiMAT!~p(3QUF.RNMEPff:EMPLOYE:AND THAT 1 HAVE <br /> I� REPOWD THIS INFORMATION TO f.QCAI.LIFE PURSUANT 7Q SECTION SM?OF. <br /> HE NEAITH ANo sAFiY IX)DE <br /> REPORT DATE CCASEST <br /> v v <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> REPRESENTING ❑ owNERfOPERATOR GK)NAL BOARD COMPANY OR AGENtYNAl E ,,.,, <br /> V LOCAL AGENCY [:] OTHER U%/V '/J"tw L.7H <br /> ADDRESS /yS /, <br /> �► 1 Bo �Ivv J /f�"'•""/0� �I STATE I -2- <br /> uJ NAME CONTACTPERSKNN PHONE <br /> m SS w O F O G�0 n! ❑ UNKNOWN 60 616 I� —8� <br /> ADDRESS <br /> 4 ZS v, RvLr b!L/�O 0 Sia c-�czv� %J'ZU <br /> STREET CRY STATE p <br /> FACILITY NAME(F APPLICABLE) PERA <br /> OT� D d ��v�C7 J� PHONE 9�,8d a <br /> .0,4- G on! — PC, l.( <br /> ADDRESS <br /> CROSS STREET TYPE OF AREA 0 COMMERCIAL❑INDUSTRIAL❑RURAL TMP BUSINESS 0 RETAIL FUEL STATION <br /> L <br /> -Doe,At ❑RESIDENTIAL 0 OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> i REGIONAL BOARD PHONE <br /> i� G �'� Gl/ GB (9>6)3 4!� -5r6 a <br /> m (N) NAME QUANTITY LOST(GALLONS) <br /> go v- ,, , UNKNOWN <br /> (21 M <br /> V YI UNKNOWN <br /> DATE DISCOVERED f", <br /> HOW DISCOVERED ❑ INVENTORY CONTROL E:) SUBSURF MONITORING O NUISANCE CONDITIONS <br /> Al7 a r r, NK❑ TATEST ❑ TANK REMOVAL x OTHER ;A/G <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Y - - % DI �J _yj UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 9 ❑ REPAIR TANK tg"REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES [:] NO F YES.DATE NJ M O p ?v • v Lg OTHER 51W J1" djnj,),� 1�S' <br /> SOURCE OF DISCHARGE TANKS ONLYr_APACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREiFALURE <br /> PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION Djr UNKNOWN <br /> ❑ OTHER CS UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> CHECK ONE ONLY <br /> I < UNDETERMINED ❑ SOL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> �q CHECK ONE ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> H ❑ NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE i DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE i TREAT(ET) ❑ PUMP i TREAT GROUNDWATER(GT) 0 REPLACE SUPPLY(RS) <br /> ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> A- Sire- 145 5 W w i L.L, &e- re,1,4I Nzerd -fo de*.8o jne <br /> G A-(i � k0 r 1 Za rj-M l e.x4e-w� or— Ga"7A*1NA'l/ <br /> HSC OS 1�J1 <br />