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d <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED ASE(LEAK)I CONTAMINATION SI <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI B L LAGENCY USE ONLY <br /> REPORT BEEN FILED? �:}f �(( RT1FY 7N <br /> A7)J�1uF:A QFaS1( k3 G£)V i MP( 3YEE'ANp Tf99sT E PfAYE <br /> YES NO YE3 NO <br /> R TH)S fF(F T1�NLOCALE MALS Rt1RANT 7Q 25ib(f 7+Jfi <br /> REPORT DATE CASE# SAFTY ` <br /> M M D f�Ea. .'._.:. :: <br /> Tg: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> a REPRESENTING COMPANY OR AGENCY NAME <br /> OWNERIOPERATOR REGIONAL BOARD lI G �tCQ® 1n1 <br /> o LOCAL AGENCY 0 OTHER %!' ® fl V/fir v/►/1$ <br /> a <br /> ¢ <br /> ADDRESS <br /> • ® STREET CITY STATE ® ® ZIP <br /> 009 <br /> NAME CONTACT PERSONS PHONE <br /> Cl/ rh/4 ,,ry vt ❑ UNKNOWN r C <br /> R ADDRESSLu <br /> Dyrn lO�y p <br /> STREl V C CITY STATE v P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> al r rn r jervicc ( ) <br /> ��uq+ ADDRESS /' ®® T Q <br /> - / � G • L01-it y e EET CITY "�® �n COUNTY / P <br /> CROSS STREET TYPE OF AREA F7COMMERCIAL INDUSTRIAL a RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> 0 RESIDENTIAL a OTHER Q FARM BOTHER t G `J/ <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W 2 li sery crs - v. H l Ner (12 01) -3`l <br /> w REGIONAL BOARD PHONE <br /> ckw &C16 <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> e -v l uNKNOwIN <br /> (2) <br /> N- UNKNOWN <br /> z DATEDISCOVERED / Ga HOW DISCOVERED a INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> �M kn D 7 DLu <br /> -/Y y 0 TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD U ED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D Y Y <br /> UNKNOWN REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> W / cL <br /> HAS DISCY SRGE❑BEEN�STOPYES,DATE !M D T o Y v ❑ SER E] REPAIR TANK �'R��R PIING E] CHANGE PROCEDURE <br /> y SOURCE OF DISCHARGE TANK/SS��ONLY/CA�PPgAyCITY MATERIAL CAUSE(S) <br /> TANK LEAK KNOWN 42-5y GAL. a FIBERGLASS � OVERFILL a RUPTURE/FAILURE <br /> El PIPING LEAK AGE 1 YRS STEEL E] CORROSION UNKNOWN <br /> D OTHER E-] UNKNOWN ❑ OTHER E:] SPILL E:] OTHER <br /> w a CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY a GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON'E ONLY <br /> Lu Cc SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F--] CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> UNO ACTION TAKEN E::] POST CLEANUP MONITORING IN PROGRESS [:] NO FUNDS AVAILABLE TO PROCEED a EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> n z [:] CAP SITE(CD) O EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) a ENHANCED BIO DEGRADATION(IT) <br /> WF7CONTAINMENT BARRIER(CB) a EXCAVATE&TREAT(ET) PUMP$TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT <br /> .�AT HOOKUP(HU) 0 NO ACTION REQUIRED(NA) E:] OTHER(Ol) <br /> Faroer <br /> z o r ,) -Jh e.Lu <br /> ,oro <br /> HSC05(447) <br />