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r <br />o4 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / C NTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />WR LOCALAGENGY USE ONLY <br />❑YES NO REPORT BEEN FILED ? <br />❑YE <br />G1EMNT:MPpY'AND�T�NTHAT W A DESm} ....... <br />j <br />FSI <br />T.RSDTHFQRMATCOLUCA.0FFCENSRAT:ECT261.. <br />OtD>THENEAiTHAY <br />REEPORTDATE <br />CASE# <br />Vm.1 Oo% oGY % v <br />PBNiNED DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />I SIGNATURE / <br />0 <br />REPRESENTING Ep'OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME a�n, <br />0 <br />❑ LOCAL AGENCY ❑ OTHER <br />s <br />a <br />¢ <br />ADDRESS C..__ <br />STREET CITY STATE ZIP <br />w <br />NAME <br />S K <br />CONTACTPERSON <br />AC ✓2 <br />PHOr�NEy <br />} <br />(�1 �(,) �S j f� <br />UNKNOWN <br />T0 ,,IG <br />�.� (il_ <br />wp Qa <br />ADDRESS Q /� C y _ /��+� / /-4 C�' •� <br />G H''I Ce" / ra..) /._ V 7 <br />/ • V C,�C ``�� / STREET / • s.C� i�I <br />STATE P <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONEN - - <br />Ua <br />� <br />ADDRESS / <br />64V4, <br />/ �S J .� � •✓Cu 2Acc � A'ii I�ICis +.�:.•I/ %�%i i � <br />� / <br />STREET CRY CCU P <br />a—i <br />CROSS STREET <br />TYPE OF AREA COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br />/ / t� <br />a RESIDENTIAL Q OTHER <br />Q FARM E::] OTHER <br />LOCALAGENCY AGENCY NAME r J <br />CONTACTPERSON <br />PHONE <br />Lu <br />$v Cz . I� •(/✓. Ale <br />(720 <br />w , <br />REGIONAL BOAR <br />PHONE <br />N <br />ZU w <br />J <br />(�) NAMEQUANTITY LOST (GALLONS) <br />l/�/V �t'.-rc"r+. S-li C..:.✓ - �/"�iH'/a , L .✓ UNKNOWN <br />Q <br />4J <br />[N— <br />(21 <br />❑ UNKNOWN <br />I <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />/ M Z M Cio S" o 7Y v <br />❑ TANK TEST ❑ TANK REMOVAL -OTHER s .� <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />iNKNOWN <br />M M D D Y Y / U <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />W <br />TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED ?REPAIR <br />p <br />lj?rYES ❑ NO IF YES, DATE M Z M D D / v �n Y <br />❑ OTHER <br />w <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK ❑ UNKNOWN <br />/CKi /CK, 9K GAL. FIBERGLASS <br />❑ OVERFILL ❑ RUPTURE/FAILURE <br />❑ PIPING LEAK <br />AGE / C, YRS ❑ STEEL <br />❑ CORROSION ❑ UNKNOWN <br />OTHER 7y`yj,: ? <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />Lu w <br />CHECK ONE ONLY <br />IL <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />cn <br />CHECK ONF' ONLY <br />r7SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS [:?*'SIGNED OFF (CLtr EANUP MMPI EYED OR UNNECESSARY) <br />a <br />ct <br />U <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />z <br />00 <br />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />Q� <br />F—]CONTAINMENTBARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) u OTHER (Ol) C�c'g4o+�r u w m <br />FN- <br />i�Ll i/J�/51 � 6 w � ii e-/�s z � Pte/ ✓� �'�,� �� l'9 a ... f�h% ..J `j 1�-� �/i✓ Q � �LZt .r-.✓ T- KfI3S' <br />ca h/ s N w I w •Gl �w� tiT'vt n. p f} Ad� S �� S u'/� n� E ti. 7� /LP��YI �, ✓ 2 <br />—t 'I <br />