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C C-� r `? <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YESNO REPORT BEEN FILED? YES NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOC OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE x�i /J CASE+ THE HEALTH AND SAFTY CODE. <br /> DM, C/ DI ! y 0 Y SIGNED DATE`/ <br /> NAME OFINDIVIDUALFILING REPORT ( / / PHONE I SIGNATURE <br /> J <br /> w REPRESENTING OWNER/OPERATOR F REGI L BOARD MPANY OR AGENCY NAME <br /> aI LOCAL AGENCY OTHER P b <br /> w ADDRESS <br /> f, V I/I1 O(/IJP <br /> ( •/ �` Z STREET � CRT STATE 21P <br /> NAME /�,. < CONTACTPERSON PHONE <br /> y� � 1 V� e I UNKNOWNt59 A <br /> Q <br /> a. <br /> C ADDRESS � 1 <br /> w l sr I'J ' /��,C cm ��� � N '? P <br /> '6 <br /> srAr n <br /> FACILITY NAME(IF APPLIICABLE) OPERATOR /PHONE <br /> p V <br /> ~ ADDRESS <br /> < �-_ <br /> w crrY courrry v <br /> ~-� eL <br /> CROSS STREET TYPE OF AR �COMMERCIAL INDUSTRIAL a RURAL TYPE OF BUSINESS a RETAIL FUEL STATION <br /> RESIDENTIAL =OTHER a FARM a OTHER <br /> p AL AGENCY AGENCY NAME r(,-171 CONTACT PERSON PHONE <br /> WLu <br /> 5� Rmblk o <br /> REGIONAL BOARD PHONE <br /> CL <br /> c v �Z I.cJ GGA (9 36/�6d <br /> (�) NAME QUANTITY LOST(GALLON <br /> WL)C3y�,� 1 ,^��� 0 !� UNKNOWN <br /> (2) N <br /> Z a UNKNOWN <br /> I <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL a SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Z /Zf v uj <br /> M D D y a TANK TEST TANK REMOVAL OTHER <br /> 10 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 2 <br /> UNKNOWN REMOVE CONTENTS a REPLACE TANK CLOSE TANK <br /> T', Mij 01 Dl V Y <br /> O HAS DISCHARGE BEEN STOPPED 7 (� REPAIR TANK E:1 REPAIR PIPING CHANGE PROCEDURE <br /> S YES = NO IFYES,DATE M Ml DI D YI Y OTHER <br /> t SOURCE OF DISCHARGE TANKS O/NLYr-APACITY MATERIAL CAUSE(S) <br /> 4 TANK LEAK �UNKNOWN /�DO GAL. FIBERGLASS OVERFILL u RUPTURE/FAILURE <br /> UQ <br /> F-1PIPINGLEAK AGE li—YRS STEEL CORROSION UNKNOWN <br /> a OTHER 160UNKNOWN OTHER SPILL 0 OTHER <br /> I <br /> w w CHECK ONE ONLY <br /> CL <br /> UNDETERMINED 0 SOIL ONLY GROUNDWATER DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK O ONLY <br /> Z n <br /> ` SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS a SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)H NO ACTION TAKEN a POST CLEANUP MONITORING IN PROGRESS a NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES (� <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O CAP SITE(CD) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) a ENHANCED BIODEGRADATION(IT) <br /> CONTAINMENT BARRIER(CB) a EXCAVATE&TREAT(ET) a PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) OTHER(OT) <br /> H I so;L s re v e-4/ Goy✓rim/�v�T o,� .�!'o M /�� et <br /> ha�l.+rs h d e�j�Ez► o t Lei,✓ t/ .�.� ,:v �a- >' G,�,5;e IF ix < <br /> oslwen <br />