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.i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE O77. <br /> FFICE OF EMERGENCY SERVICES FOFi LOCALAGENGY USE QNLY <br /> REPORT BEEN FILED 7 YES <br /> NO p EEpq}�aEA fiii5 IIyFf7€�MR3�O1V T'� LC)CA1T t)FE AL$t URS E�JO.S G 145N 25380 7AOF <br /> ❑ YES NO <br /> ' THE4i Al3lJ�AFTY <br /> REPORT DATE pl CASES <br /> GATE, <br /> SEC4N <br /> OM M o y ySIGNA <br /> NAME OF INDIVIDUAL FILING REPORT PHONE j <br /> 11 (ON, <br /> yMPANY OR AGENCY NAME <br /> L CO '. I <br /> o REPRESENTING �OWNEWOPERATOR ❑ REGIONAL BOARD LOCA{ /L� <br /> I! <br /> LOCAL AGENCY ❑ OTHER SAN O/1 U f <br /> . t"/ LTff /5 �1G7� <br /> O <br /> ADDRESS O I 5rXA) <br /> '(bQ �i OTY STATE 21P <br /> y sTREEr <br /> u�I� CONTAGTPERSON /.PHONE <br /> NAME �1 yULr IN I/ Si/LfE�� 1 (V/sl - <br /> y I ❑ UNKNOWNL� N <br /> g 4 <br /> z <br /> IL <br /> ADDRESS <br /> Q <br /> K �(/�Q • /v��''r, STREET CfYY STATE. ZIP <br /> OPERATOR PHONE <br /> FACILITY NAME(IF APPLICABLE) r <br /> � la <br /> r ADDRESS ]//' qI� <br /> ST,--Al- <br /> Cm, COUNTY P <br /> STREET <br /> CROSS STREET i� TYPE OF AREA ❑COMMERCIAL tg INDUSTRIAL❑RURAL TYPE OF BUSINESS [:] RETAIL FUEL STATION <br /> fn RESIDENTIAL ❑ �QT� OTHER ❑ FARMHER'J-rl���"" "'•'� ❑ <br /> LOCAL AGENCY A AGENCY NAME CONTACTPERSON. PHONE <br /> W cll;n� �-6GfI <br /> w PHONE <br /> w <br /> —REGIONAL BOARD <br /> V ' ( ) <br /> le VY <br /> NAME OUANTRYLOST(GALLONS) <br /> UNKNOWN <br /> �C3 <br /> ;i <br /> (2) y ❑ UNKNOWN <br /> iDATE DISCOVERED I.I HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORING i:❑ NUISANCECONDITIONS <br /> Lu ! ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> M M 0 Y Y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> DATE DISCHARGE BEGAN I II'' <br /> QI UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> Ml MI Di Di ylQQQn HAS DISCHARGE BEEN STOPPED 7 y ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> C3 RYES ❑ NO IFYES,DATE �M M o o v y ❑ OTHER <br /> Lu SOURCE OF DISCHARGE TANKS ONLYrCAPACITY MATERIAL CAUSE(S) <br /> D �TANKLEAK ❑' UNKNOWN I�� OI _GAL. ❑ F113ERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> PIPING LEAF( AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER <br /> II UNKNOWN E::] OTHER ❑ SPILL ❑ OTHER <br /> w a CHECKONEONLY <br /> U ❑ UNDETERMINED I Ok:l_SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY li Ij <br /> z ❑ <br /> 517E INVESTIGATIlN IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> y E] NO ACTION TAKEN. E::] POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> REMOVE FREE PRODUCT(FP) ❑ EIBtO DEGRADATION(IT) <br /> z El24 CAP SITE(GD) (� ❑ EXCAVATE&DISPOSE(ED) ENHANCED❑ �I <br /> W ' PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET} ❑ ❑ y <br /> ¢ ❑ TREATMENT AT H(,)OKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) Ij <br /> I 5i7 A55�Srul NT �I/r� 73�` ,e�gvt !> TD i-- -F n�L <br /> Tr<f� N TvI rX rCNT- OF c(-), -ring TiD� ,J 2E�ur2 � <br /> I I <br /> II HSC MJ447) <br /> I <br /> 1�07 <br />