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UNDERGROUND STORAGE TANK UNAUTHORIZED.RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY:'ySE ONLY;: <br /> EMERGENCY REPORT BEEN FILED t:FiEAE$Y CERTIFY THAT E AM A�}ESIGNAT€D GQVERNMENT EMPLOYEE AND THAT!NAVE <br /> ❑YES NO ks'PUFlSUAN] TQ SECTION 251bnr OF: <br /> ❑ YES NO REPQRTED T <br /> REPORTDATE �! CASES <br /> S NED " E. <br /> OM` MI II [rI r SIGNATURE <br /> NAME OF INDIVIDUAL.FILING R PORT PHONE ` <br /> C3 REPRESENTING ❑ OWNE WOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Fj?jZCAI AGENCY ❑ OTHER + �s�+ <br /> CE ADDR15,$ 5,4M <br /> _To <br /> 7 F �Q� � ! �� Z <br /> ATE <br /> STREET CITY <br /> PHONE <br /> NAME r�+ j CONTAAC}TPERSON <br /> �J� <br /> 9 II ❑ 'UNKNOWN <br /> < ADDRESS <br /> vIS `TFJL <br /> STATE <br /> b STREET crry <br /> U'T� <br /> ` <br /> FACILITY NAME(IF APPLICABLE) OPERATOR' PHONE <br /> a ADDRESS !I2-6 <br /> aw"Ty ZIP <br /> STREET.Lu <br /> - CITY <br /> '= <br /> GROSS STREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRAL�AL TYPE OF INESS RETAIL FUEL STATION <br /> rn , <br /> ❑RESIDENTIAL ❑OTHER FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME �M .fyQL CONTACT PHONE <br /> W�y <br /> v� Ij S °%t ►� .ar. Fi2lGEvE.0�— {Zc ) V7S—3;l3 <br /> w Lu REGIONAL BOARD PHONE <br /> (11 NAME QUANTITY LOST(GALLONS) <br /> I! <br /> UNKNOWN <br /> y_ I' ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED i ❑ IN NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> W TANK TEST TANK REMOVAL ❑ OTHER <br /> 0M MI' I o o �Y l r. ❑ <br /> � <br /> DATE DISCHARGE BEGAN 'METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)El.I I <br /> UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> -1: M. D D Y V <br /> HAS DISCHARGE BEEN STOPPED 4 <br /> REPAIR TANK ❑ .REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YESi-❑ NO IF YES.RATE uI .I DI 01i r Y ❑ OTHER <br /> Lu SOURCE OF DISCHARGE TANKS ONLY/CAP=TY MATERIAL CAUSES) <br /> ❑ " e6 3 ! FIB GLASS OVERFILL �TUREIFAILURE <br /> TANK LEAK UNKNOWN _ GAL. r ❑ ❑ ❑ <br /> ❑ NPIiNG LEAK AGE YRS } STEEL ❑ CORROSION UNKNOWN ' <br /> i�. <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W W CHECK ONE ONLY <br /> U� ❑ UNDETERMINED S ILONLY ❑ GROUNDWATER '❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY E <br /> INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> I� A I <br /> V NO ACTION TAKEN ❑ POST CLEANUP MONITORING 1N PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) k _ <br /> REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(M <br /> c 4 ❑ CAP SITE(CO) ❑ EXCAVATE d DISPOSE(ED) ❑ { <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) <br /> ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ .OTHER(OT) <br /> S < /PBst�GTs LiQp� TIG-/�(� �4E"vCIA C-- -'rq£ <br /> Fri (F Srt A�F�4,6evr avct-L eWQ�I!°F� rs. D€? ° r/i►� <br /> 7'F- ,AJ 4n, 41V-0 4,MCA -7-a cont T�!1�c<IV 7`�a�11/¢S /415k? r <br />