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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGc'tiCY SERVICES ;FON LOCALAGEN,CTOSE QNLY.,:.... <br /> REPORT BEEN FILED? 1:HEREBY CERTIFY THAT:[:::AM:A OESIGNAT� AMEANMENT EMPLOYEE ANQ C�JAT!HAVE:: <br /> 0 YES NO C;YES 0 REPOF#TED TI41S,:INfMMA )ON?O LOCAL::WICIALI.Ss:FURSIIAN ,TG:SEC K)N.2$!$V:O£_ <br /> REPORTDATE CASES SAFTY - <br /> 0M1 M O C�0 Y ■ Y ,SIGRi -. - > <br /> „�uITE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m r e A (o 3 a4 <br /> REPRESENTING OWNERIOPERATOR C REGZNAL60ARD Com PANYORAGENCY NAME <br /> p LOCAL AGENCY E] OTHER �� G f .c J . <br /> a <br /> ADDRESS <br /> �y� �) �y.�} <br /> •�/' 'JV STREET (�b^�T CI GN C/ 1 SPATE ZIP <br /> NAME S 1CONTACT PERSON PHONE <br /> i� JY1L UNKNOWNLu <br /> t ✓� !< �V�� <br /> ,V•—?50 fJ STREET , ` O CITY STATE ?g% DP <br /> FACILITY NAM E(IF APPLICABLE) A OPERATOR PHONE <br /> La ADDRESS [�+� r� <br /> J• 4o�40 DEET �j cm 54,4,L V�Z G(l P7 c -Ty P <br /> y CROSS STREET TYPE OF AEA 91 COMMERCIAL F7INDUSTRIAL 0 RURAL TYPE OF BUSINESS Q RERET"ARIL FUEL STATION k <br /> C RESIDENTIAL OTHER FARM S] OTHER •ytpl[,S•rt- E <br /> LOCALAGENCY AGENCY NAUE CONTACTPERSON PHONE <br /> rn <br /> W v�Va2 L4 F 1� 1 c. l �) <br /> w Lu REGIONAL BOAFfD PHONE <br /> e� f ) <br /> {1) NAME - QUANTITY LOST(GALLONS) <br /> rn pp <br /> e 4 UNKNOWN <br /> J <br /> r� (2) <br /> y Q UNKNOWN <br /> Z DATEDISCOVERED HOWWDIISCCVEaED INVENTORY CONTROL SUBSURFACEMONETORING E:] NUISANCECONDITIDNS <br /> 2 0.102_. Qo .1 r r Iry TA.WTEST F TANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> } M M UNKNOWN 'REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> � o o Y Y 1 <br /> DQE p HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> ❑ YES ❑ NO IFYES,DATE MI 01 DI rI r ❑ OTHER <br /> N SOURCE OF DISCHARGE TAN ONLYCAPACITY MATERIAL CAUSE(S) <br /> F7 TANK LEAK K UNKNOWN GAL. FIBERGLASS OVERFILL RUPTURErFAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL CORROSION UNKNOWN <br /> • OTHER LN(NOWN OTHER O SPILL = OTHER 1 <br /> w w CHECK ONE ONLY ) <br /> a <br /> v� <br /> UNDETERMINED SOIL ONLY I GROUNDWATER DRINKING WATER• (CHECK ONLY IF WATER WELD HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY p <br /> SITE INVESTIGATION IN PROGRESS(DEFINING STENT OF PROBLEM) CLEANUP IN PROGRESS = SIGNED OFF{CLEANUP COMPLETED OR UNNECESSARY} <br /> U w 19 NO ACTION TAKEN — POST CLEANUP MOYITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPRCPRIATE ACTION(S)(SEE BACK FOR DETAQ.S) <br /> z = CAP SITE(CD) EXCAVATES DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(17) <br /> E] CONTAINMENT HARRIER(CB) EXCAVATE 3 TREAT(ETI PUMP 8 TREAT GROUNDWATER(GT) F REPLACE SUPPLY(RS) <br /> 1 Q TREATMENT AT HOOKUP(HU) NO ACTION REOUIRED(NA) OTHER(OT) �,tiQQfIJ t�� <br /> cD t� -�.e.D�'• �7t.c.�_ ��e._ W�.2�...�' t.Nt.Q.G¢.��� <br /> 4,o c6- <br /> sHSC 05I.AFn <br />