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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> YES NO 0 YES �,HFREBY.. RTIFY THAT f AM: M81GNAtED GOVFF(NMENt EAIfiLaYEE:-AND THAT. HAVE; <br /> itEPOfITE 15 INFORMATION T pFFlC URSUANT TA SECTIOFI 251A07 OF' <br /> REPORT DATE CASEA THEN dSAFfY �y+' <br /> DATEJ:< <br /> NAME OF INDIVIDUAL FILING REPORT " <br /> PHONE -- SIGNATUR r <br /> Gl co <br /> REPRESENT <br /> OWNERIOPERATOR Q REGIONAL BOARD, COMPANY OR AGENCY NAME <br /> EL OCAL AG NCY OTHER p u-. _ <br /> Hq <br /> Ir ADDRESS (_ �j }�, , ( : <br /> STREET -InZ2-e- 1 (!I, <br /> CITY STATE <br /> NAME CONTACTPERSON PHONE <br /> in <br /> Z <br /> ,fA:�- ,,, y <br /> z �TL.e�rr~ UNKNOWN <br /> a ADDRESSul <br /> 4- <br /> a STREET b��m � CRY SGrr��� `-^ �. I <br /> STATE p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> fl <br /> Uc ADDRESS <br /> 1 i✓� STREET I t7` CRY r C.OUHTY p�•� /L ' <br /> ro CROSS STREET TYPE O REA <br /> �j �RCIAL a INDUSTRIAL a RURAL TYPE OF BUSINESS ETAIL FUEL StATION <br /> I o3v&,D_ 0RESIDENTIAL 0OTHER 0 FARM 0 OTHER f <br /> LOCAL AGENCY AGENCY NAME 'CONTACT PERSON <br /> _ PHONE- <br />. <br /> z S� o kr1J <br /> a REGIONAL HOARD <br /> PHONE <br /> 2 I I , <br /> Lu NAME OUANTITYLOST(GALLONS) <br /> � � <br /> F OfCh NKNDWN i <br /> (2i <br /> E] UNKNOWN <br /> w <br /> DATE DISCOVERED HOW DISCOVERED E::) INVENTORY CONTROL SUBSURFACE MONITORING NUISANCECONOITIDNS <br /> o M M o &-, g Y TANK TEST O TANK REMOVAL � OTHER <br /> GATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> w M M <br /> DI DI Y Y dUNKNOWN REMOVECONTENTS 0 REPLACETANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK 3EPAIR PIPING CHANGE PROCEDURE <br /> $ F-1 YES E7] NO IFYES,DATE M M o o r Y Q OTHER <br /> N SOURCE OF DISCHARGE TANKS ONLYrCAPACI IY MATERIAL CAUSE(S) <br /> TAKLEAK UNKNOWN GAL. Ej FIBERGLASS OVERFILL RUPTU LURE <br /> PrP1NG LEAK AGE YRS 0 STEEL 0 CORROSION KNOWN <br /> 0 OTHER O UNKNOWN Q OTHER E:l SPILL 0 OTHER <br /> CHECK ONE ONLY } <br /> V UNDETERMINED E:] SOILONLY GROUNDWATER 0 DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) t <br /> F CHECK ONE ONLY - <br /> z m <br /> c 5ZS1TE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS Q SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢� <br /> U y Q NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> 50 CAP SITE(CO) � EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(Fp) Q ENHANCED BIO DEGRADATION(IT) <br /> CONTAINMENT BAARiER(CB) a EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) �ER(OT) <br /> Z <br /> rp !Jncc1rcr-Lu <br /> JAI- <br /> � cis �Q <br /> HSC05(1871 <br /> i <br /> A <br /> ai <br />