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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 /> REPORT BEEN FLED? <br /> YES NO REPORT <br /> YES CK No }HEREBY.CERTIFY.THAT CAM A OESIGNATEp GOVERNMENT EMPLOYEE/IND THAT!'NAVE: <br /> REPORTED.THIS INfOgMATION TO LOCAL-OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE• THE HEAL SAFTY <br /> SIGNED. GATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATU <br /> lkoe--- <br /> REPRESENTING Q OWNER/OPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 LOCALAGENCY 0 OTHER <br /> a <br /> cr <br /> ADbRESS <br /> 111401 e&� TREET CITY 641 STATE ZP <br /> Lu E NAMCONTACT PERSON PHONE1. <br /> Z ❑ UNKNOWN POP <br /> a <br /> Lu <br /> ADDRESS <br /> cc <br /> tz <br /> �. <br /> STREET CITr C/rf STATE �Z �ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> i ADDRESS <br /> wNU ssFtEET Cm W. ✓�`�P <br /> rn CROSS STREET TYPE OF AREA a COMMERCIAL INDUSTRIAL O RURAL TYPE OF BUSINESS 0 <br /> R�T/11L <br /> STATION <br /> 0 RESIDENTIAL. 0 OTHER Q FARM � OTHER Or��LJyAGZ(*p��! <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> UJ (tZ! �f�8� <br /> w 0 REGIONAL BOARD PHONE <br /> if<fA w (1) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> U <br /> UNKNOWN <br /> (a <br /> O UNKNOWN <br /> w DATE DISCOVERED Q� HOW DISCOVERED <br /> a INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> to <br /> M M D (�Y O r TANK TEST TANK REMOVAL fiq <br /> OTHER �f�(L j6 d(kJ fQ{�YS(� Cr <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> } UNKNOWN O REMOVE CONTENTS a REPLACE TANK CLOSE TANK <br /> Mi. M D D Y YJ w <br /> NQS HAS DISCHARGE BEEN STOPPED? Q 0 REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p I YES [:] NO IF YES,DATE Q -�M .1 q.1 �r �v OTHER TAW oileD <br /> Lu SOURCE OF DISCHARGE TANKS ONLWCAPACITY MATERIAL CAUSE(S) <br /> a TANK LEAK X UNKNOWN 5120 GAL. Q FIBERGLASS O OVERFILL Q RUPTURE/FAILURE <br /> I�1 i <br /> j a PIPING LEAK AGE YRS STEELa CORROSION X[ UNKNOWN <br /> OTHER UNKNOWN a OTHER a SPILL a OTHER <br /> w CHECK ONE ONLY <br /> U1192 UNDETERMINEDSOIL ONLY GROUNDWATER <br /> 0 � O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> ZN <br /> Cc <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) a CLEANUP IN PROGRESS a SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc v~ NO ACTION TAKEN <br /> O1 0 0 POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED [:�] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Z [--] CAP SITE(CD) O EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> cc <br /> CONTAINMENT BARRIER(CB) EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> O <br /> O TREATMENT AT HOOKUP(HU) a NO ACTION REQUIRED(NA) OTHER(OT) <br /> rn <br /> I- <br /> 2 <br /> 8 <br /> I <br /> HSC Q5(4A71 <br /> I <br /> I <br />