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II <br /> 3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I,�CONTAMINATION SITE REPORT !� <br /> i <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ! FOR LOCAL'AGEN fJSE NLY ;! <br /> ❑ YES ❑ <br /> REPORT SEEN FILED 9 ❑YESE:l No E I HEREBY CEFiTI T T I' S EO GOVE�iNMfNt. MPLOYE .AND THAT I HAVE' <br /> REPORTED'THE tNE M T. flFFICIlLLS:;Pl1ii5LJANT TO SECTION 25180 7 OF r <br /> REPORT DATE CASES THE HEALTH <br /> o b yj r S*NED <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> j <br /> ` l Zc '7 Lf b p-. I 9 '' <br /> m GlV1a G0.r iS `7'T o ie <br /> a REPRESENTING Q OWNED OPEAATOR � REGIONAL BOARD COMPANY OA AGENCY NAME ii y <br /> Ir <br /> LOCAL AGENCY E—] OTHER <br /> a - SGS VooL vih � 40�.�-1 11�.a�1✓�' �,�-YIc1 <br /> ,a <br /> Q ADDRESS h <br /> tbC7� � , �4-�el�a�t ���• Amy Zc:7o� C �-1y oh :- � r 11. : <br /> STREET <br /> Ci7Y 'I. STATE'S 21P II <br /> 9 NAME n ;I:. CONTACT PERSON PHONE �F <br /> El UNKNOWN <br /> IL ADDRESS <br /> q 1v✓ 2✓ ltcS Lc�c1� <br /> STREET CRY .if 97,7E`'i <br /> P <br /> FACILITY NAME(IF APPLICABLE) �^ OPERATOR <br /> PHONE c G 7 11 <br /> ��t tOJ rt�o1O,n 1_j¢c� "S [�0�� 0 �a >S}s' <br /> i ADDRESS u <br /> �• '[ 1fC1 CouaTr <br /> STREET I=' . <br /> F .CRY � � ,-i <br /> y CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL�RURAL TYPE OF BUSINESS RETAIL FUEL STATION;i <br /> G�[Y q �.4O RESIDENTIAL OTHER �C]J a FARM OTHER ,n <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE 3 <br /> p w <br /> Lu L REGIONAL BOARD t ! - <br /> PHONE <br /> s <br /> Ce�+f.,t V�.((� <br /> t�ov�.o,.. Da <br /> {1) NAME -` Il 1E <br /> B OUANTITY LOST(GALLONS) i <br /> S O�0., pQ�vJ`G..w Y} dvo C�r(ao S O�+cyu UNKNOWN i <br /> t I UNKNOWN <br /> DATE DLSCOVERED FIDW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBST RFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 1:f-Y ❑_ TANKTEST TAW REMOVAL ❑ OTHER S s ! <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) �. <br /> HJTi' <br /> Y M o a r V`I UNKNOWN ❑ REMOVE CONTENTS I❑;j REM-ACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPNI G ❑ CHANGE PROCEDURE <br /> a YES ❑ NO FYES,DATE M �o o �r 5v ❑ OTHER <br /> SOURCE OF DISC14ARGE TANKS ONLY,CAPACITY ; MATERIAL n CAUSEfS) n <br /> h <br /> TANK LEAK ❑ UNKNOWN (}AL, FIBERGLASS I ❑ OVERFILL ❑ RL'PTUREIFAILUiE <br /> LK AGE YRS STEEL <br /> ElPIPINGEA ❑ CORROSION ',;Z] UNKNOWN <br /> y ❑ OTHER UNKNOWN OTHER tG✓C7�°iEl SPILL OTHER ; r <br /> tv CHECK ONE ONLY s' <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER `_,❑ DRINKING WATER- (CHECK�DNLYIFWATERYVELLSHAVEACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ,CLEANUP IN PROGRESS <br /> Q. a i SIGNED OFF(CLEANUP COMPLETEDOR'UNNECESSARY) ! <br /> NO ACTION TAKEN ❑ POSTCLEANUP MONITORING IN PRDGRESS ❑ NO FUNDS AVAAABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> 3: <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) t' 'is • <br /> ❑ CAP SITE(CO). ❑ EXCAVATE 8 DISPOSE(ED): ? ,❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BO DEGRADATION(FTS <br /> ❑ CONTAINMENT BARRIER(CB) O EXCAVATE a TREAT(ET) � � � PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ <br /> TREATMENT ATHOOKUP <br /> 1(HU) ❑ NO,SACTION REQUIRED(NA); Q OTHER(07) iy� r o c rf, i7 <br /> ,.: 5Cl 1W�"�TO�w+�i v�A 1'aM Ko��� �Ivd IMat �OK����.4Nti.0�4\, �"1 1 � vVs�"VIS„', � � I� •� <br /> } <br /> ' 1! MSC 9614E71 I <br />