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12 ll go -- P� aid &-r , .-1 , 'L&- ,Z;�3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYNO HAS STATE OFFICE OF EMERGENCY SERVI S FOR LOCAL AGENCY USE ONLY <br /> ❑ REPORT BEEN FILED 7 <br /> YES I HEREBY CFRTIFY THAT I AM A DESIGNATED GOVERNMENT;EMPLOYEE ATHAT I HAVE'. <br /> ❑ YES �_ ND REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION:25180.7 OF <br /> REPORT DATE CASE s T)IE HEALTH AND SAFTY CODE. <br /> �Y / Y SIGNED <br /> DATE <br /> N F INDIVIDUAL FILING REPORT "'- <br /> PHONE SIGN <br /> > Him lfi6 ��'-f VA y6o r_3 c <br /> w REPRESEfJTING OWNER/fn OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME /////-�/��,�� <br /> p LOCAL AGENCY O OTHER E/ r 1) <br /> Q AD S <br /> �5 /1/ Tom t.-'/7 <br /> STREET � <br /> NAME 1 CO ACT PERSON STATE ZIP <br /> co ran e s <br /> z¢ V"V(ASI) UNKNOWNT/!/ l�Q/ 'L of / 7� ' /G 36 <br /> 2 ADDRES <br /> a <br /> w � qZ Al }� v� -r �stvc�c fm 6) <br /> STREET CITY STATE ZIP <br /> FACILI NAME(IF APPLICABLE) OPERAT R PHONE <br /> h ��r GcIQ sh �'imv C n (Z0% 9y8-1636 <br /> t ADDRESS <br /> MY <br /> (p CRDia, <br /> TREET TYPE OF AREA ❑COMMERCIAL ❑ INDUSTRIAL RURAL TYPEOFBUSINESS <br /> RETAIL FUEL STATION <br /> K ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> z <br /> w� c � <br /> w REGIONAL BOARD PHONE <br /> CL¢ li 1 CiIJ / <br /> NAME QUANTITY LOST(� OWN <br /> ALLO <br /> Lu !J <br /> z (2) <br /> cn V I / 7� %1 4 1� (/ice i/�G'� Ki�6) (�UNKNOWN <br /> r DATE DISCOVEREDDISCOVERED <br /> w /�❑ I NTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w M 0. p SIT v v Y HO❑ TANK TEST TANK REMOVAL a OTHER <br /> DATE DISCHARGE BEGAN / METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Cc M M D o Y r ®/U/NKNOWN O REMOVE CONTENTS ❑ REPLACE TANK E:] CLOSE TANK <br /> 0 HAS DISCF{pRGE BEEN STOPPED 4 ❑ REPAIR TANK XPAIRPIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES.DATE M M DI DI YJ Y OTHER /GZ17 <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) t <br /> TANK LEAK UNKNOWN GAL. FIBERGLASS❑ ❑ OVERFILL �❑�RUURE/FAILURE <br /> cc <br /> PIPINGLEAK AGE YRS STEEL CORROSION OWN (U <br /> ❑ OTHER E:UUNKNOWN OTHER ❑ SPILL ❑ OTHER <br /> LU w CHECK O NLY <br /> a <br /> v UNDETERMINED a SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> z� <br /> �a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> v ❑ 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 /> 4Z ❑ CAP SITE(CD) a EXCAVATES DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> 00 <br /> uj <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT)i <br /> def o 4- <br /> a9 �, HSC05(4187) <br />