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Name <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? L<HEREBY CERTIFY THAT E AM A DESIGNATI Q.GOVERNMENT EMPLOYEE.AND THAT.(HAVE <br /> �] YES No YES NO REPORTED TMS INFORMATI TO..LOCAL.OFFlCxs PURSUANT T4 SECTION 41667 OF <br /> SIGN <br /> REPORT DATE <br /> x THE ND Y <br /> ED <br /> M M D Y <br /> YF rsWE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE <br /> m eJ 5 ! OR AGENCY NAME <br /> REPRESENTING ❑ 0WNEFVOPERATOR ❑ REGIONAL BOARD �} <br /> LOCAL AGENCY [:] OTHER Q� 1 <br /> a <br /> ADDRESS �y[.(�\J Qf f <br /> ^�io `� O >3TREET C` /-lC_.i/ 'TY LY SPATE /�`? ZIP <br /> NAME CONTACT PERSON PHONE <br /> Z [I 1 er-5 T41L UNKNOWN <br /> a ADDRESS <br /> c (p a 5 cr-E -Dr�E) OwAi6 GfYY $TATE ZIP <br /> FACILITY NAME(IF APPLICABL OPERATOR PHONE <br /> Z-au.r �ac� <br /> ADDRESS <br /> oo ` S+ + 4^ O 7 &CA cIrYsI� Vo4 ul o COUNTY l��/ P <br /> CROSS STREET Ulh PE OF AREA COMMERCIAL Q INDUSTRIAL=RURAL PE OF BUSINESS 0 RETAIL FUEL STATION <br /> h ❑RESIDENTIAL ❑OTHER FARM OTHER <br /> r LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> —Reuss PHONE <br /> —3q.7-6 <br /> w � 11 uin <br /> PHONE <br /> wLUREGIONAL BOARD r ` <br /> a 1 I <br /> (1 NAME QUANTITY LOST(GALLONS) <br /> LLIe d aa,so} /2 -e <br /> UNKNOWN <br /> O (2) <br /> UNKNOWN <br /> t DATE DISCOVERED ice^ `��] HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Z D M (J M I D 4J D S Y ! Y <br /> ❑ TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Y` X UNKNOWN � REMOVE CONTENTS � REPLACE TANK L] CLOSE TANK <br /> 6 M M D D Y Y <br /> 7HAS DISCHARGE SEEN STOPPED? ❑ REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> -p N YES L] NO IF YES.DATE QM �M ) D D Y Y � OTHER <br /> N SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK UNKNOWN <br /> ,DO Q GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ¢ PIPING LEAK AGE YRS STEEL CORROSION UNKNOWN <br /> OTHFR UNKNOWN OTHER SPILL OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wNk <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc PF <br /> � <br /> " ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS [—] No FUNDS AVAILABLE TO PROCEED [1] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> Z5 <br /> o ❑ CAP SITE(CO) ❑ EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> w� CONTAINMENT BARRIER(CR) EXCAVATE&TREAT(ET) PUMPS TREAT GROUNDWATER(G7) REPLACE SUPPLY(RS) <br /> Ir TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) OTHER(OT) <br /> � ..�P .0 �c.cee cue&.p - ' <br /> u,y <br /> HSG OSfIB7I <br />