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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> ' EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FSR LQCALAGEtiCYllS� <br /> ❑ �rND REPORT BEEN FLED 7 <br /> YES i�31 . <br /> []YES �NO ,f-HEHF�IF.#N IF1!:TFUIT� i� '�dOhl W11EN3" 11��J�D�{iA'�#111U11:, <br /> .S�Tigl! ,tKlot OF <br /> REPORT DATE <br /> CASE* } SAFYr <br /> 0 <br /> NAME OF INDIVIDUAL FILING REPORT E SIGNATURE <br /> m 4AACL <br /> w REPRESENTING 04 <br /> ❑ OWNIEM ERATOR REGIONAL BOARD COMPANY OR AGENCY <br /> �I <br /> ° PjTTOCALAGENL'Y ❑ OTHER <br /> GG+h Lacs.. r P�-E C/15 <br /> a <br /> cc <br /> NAPAt <br /> AGGRESS <br /> !I CONTACT PERSON I P <br /> — 1cr`!L `PHONE <br /> i� s UNKNOWN <br /> d ADORE <br /> Lo <br /> I a � /� snaEETTr <br /> 9r3 j <br /> FACILITY NAME(F APPLICABLE) cRr Q �� <br /> _ OPERATOR PHONE <br /> An --Qo r- ! ( 1 _ <br /> , � :2 STREET TYPE OF AREA <br /> N'COMMEWAAL❑KXISTRGL❑RURAL TYPE OF BUSINESS RFTAIL FUEL STATEN <br /> _ ❑RESIDENTIAL OTHER ❑ FARM OTHER <br /> LOCAL AGENCY NAVECO <br /> REGIONAL NTACT PERSON PHONEawl _ <br /> E LCI I GZ �� �6 3 2 <br /> PHONE <br /> J NAME QUANTITY LOST C ;'�d!I ��7 ! ,�C �-T�NoN3, <br /> ❑ UNKNo`MNI <br /> DATE DISCOVERER NHOW D19COYEREO INVENIaAY CONTROL SUBSURFACE MONITORING NULSANCE CONOTTIDMS <br /> oy MI /.I 0. �"! Y ❑ TAhIK NK TEST TAREMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> cr w y UNKNOWN REMOVE CONTENTS REPLACE TANK PR—CLOSE TAMC F <br /> HAS DIS0"RGE BERN STOPPED? r REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE 1 <br /> o Fiir YES ❑ No F YES.DATE '0u 0 0_ C D Y I OTNEFI <br /> Lu w SOURCE OF DISCHARGE TANKS ONLYC PACITY MATENAL CA1SE(S) <br /> TANK LEAK a? UNNKNOWNC { FFBER(RI ASS <br /> ❑ ❑ OVERFILL RUPTURE.'FALURE <br /> PEPING LEAK AGB4:2- _YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UAKNOWN n OTHER ED SPILL OTHER <br /> W� CHECK ONE ONLY - <br /> r� UNDETERMINED SOIL ONLY ® GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY 9EEN AFFECTED <br /> CHECK ONE ONLY <br /> SITE INVESTIGATION IN PROGRESS(DFFTNNG EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP CONPLCW OR LtNNEMSSARY( <br /> ND ACTION TAKEN ❑ POSTaxANUP moNITIDRm IN PROGRESS No FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ .CAP SITE(M ❑ EXCAVATE A DISPOSE(ED) REMOVE FREE PRODUCT(Fp) � ENHANCED 1310 OEGRADATION(IT) <br /> CONTAINACER7 BAR;,iER{(B) CI EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GI) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOO.'SIP MW NO ACTION REQUIRED(NA3 ❑ OTHER(OT) <br /> M1C�Iv7F <br />