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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION I REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG SERVICES L AGENCY U5E ONLY <br /> REPORT BEEN FILED? }i EiEa.1f f.E T�FY.THAT I AM OESI Ag AVER EMPCOYE� [+)E1 TROT. HAVE; <br /> ❑ YES NO YES NO <br /> THEE fF1F T)OM W=A4 #F(CIA1 PURSUANT TQ SEGTpNi8f17 t <br /> iSAM <br /> REPORT DATE CASE# . <br /> . . " <br /> M D D Y Y `: (GfrEB.. ':.. .,i;'.:;: ;ii :: ..-4w-w4'. ` .... ".:;i : :i TE" <br /> NAME OF INDIVI UAl FILING REPORT PHONE SIGNATURE <br /> u <br /> V091 ) <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAM <br /> ® LOC ❑ OTHER � - w <br /> a <br /> s ADDRESS <br /> 9 'C 'l"u GTRL+nt�:! CITY CA STATE 4754ZO t ZIP <br /> NAME <br /> ul <br /> CONTACTPERSON PHONE <br /> N o ❑ UNKNOWN 1 (20?) <br /> a ADDRESS <br /> cr ftp STREET CfTY SPATE N496P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 4Afwtii�Aa c <br /> ((Q< ADDRESS It <br /> 205 <br /> t saw STREET CITY A, COUNTY P <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS E::] RETAIL FUEL STATION <br /> 0 RESIDENTIAL ❑OTHER ❑ FARM OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W e "P <br /> ui <br /> REGIONAL BOARb PHONE <br /> (1) NAME QUANTITY LOST(GALL <br /> UNKNOWN <br /> (2 <br /> ❑ UNKNOWN <br /> I DATE DISCOVERED HOW DISCOVERED VE:] INVENTORY CONTROL ® SUBSURFACE MONITORNVG ❑ NUfSANCE CONDITIONSM M o v Y ❑ TANKTESTTANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D D Y Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> > HAS DIS ARGE BEEN STOPPED? F-] REPAIRTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> ® YES ❑ NO IF YES,DATE M1 11 DI D1 Yl ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY)CAPACITY MATERIAL CAUSE(S) <br /> D ❑ TANK LEAK Ekl UNKNOWN 0GAL. ❑ EMERGLASS ❑ OVERFILL TUREIFAILURE <br /> CC ❑ PIPING LEAK AGE YRS Ff"STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONS ONLY <br /> e ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U N ❑ 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 /> 0 z F-1CAP SITE(CO) F-1EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> de4frml,e -#w- <br /> W tet' ` e A Jlf <br /> HSCos(w <br />