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) <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCYUSEONLY ' <br /> REPORT BEEN FILED i I:HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT t HAVE <br /> vis No =YES No jMIORTED THIS INFORMATION TO-LOCAL OFFICIALS PURSUANT�TO SECTION 25180.7 OF <br /> REPORT DATE CASES T HEALTH AND <br /> v.ac_ SAFY <br /> necUCDCDEq. pr��,.•-N ( t l <br /> 4 <br /> �7•t-f6k' <br /> SIGNED DATE:. <br /> NAME OF INDIVIDUAL FLING REPORT PHONE S77r avTG <br /> GL ar(.S (Zoq) <br /> REPRESENTING = OWNEIVOPERATOR = REGIONALBOARD COMPANY OR AGENCY NAME / } `\ 1 <br /> SLOCAL AGENCY OTHER �„� �bS �I- Loc^I �-��„I 1� �J�S"j✓iJ- <br /> ¢ ADORES L/'T <br /> 9TREE'f CRr SEAT! ZIP <br /> NAME1 C(ONTACTPERSIION PHONE <br /> (Z�4) <br /> i ADDRESS I C A- <br /> y�ET crry srAre v <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> Fk-cc�✓o <br /> ADDRESS rr <br /> $Z I S lav\ U3N -�Ch �'v- <br /> ai CROSSSTREET TYPE OF AREA = TYPEOFBUSINESS O P <br /> y COMMERCIAL WDUSTRIAL RURAL flETAII FUEL STATION <br /> =RESIDENTIAL =OTHER = FARM = OTHER <br /> LOCALAGENCY AGENCY NAME `\ 1 COONTACTPERSON I PHONE <br /> Fw Sa\...�o.\ �.,\,\ Loc...1 Ne..5li4 V\S�vr�l Lai.✓ice -.,ll� ILL rod' -?((24 <br /> ws� <br /> w RECO AL BOARD ( PHONE <br /> (1) u NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> UNKNOWN <br /> i DATEDISCOVERED HOWDISCOVERED = INVENTORYCONTROL SUBSURFACEMONITORWG = NJISANCECONDRIONS <br /> 2 ( u 2M C1.1 o r J v TANK TEST TANK REMOVAL Q OTHER <br /> 3 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ¢ UNKNOWN REMOVECONTENTS REPLACE TANK CLOSE TANK <br /> w u M o1 01 Yl r <br /> HAS DISCHARGE BEEN STOPPED? r REPAIR TANK REPAIR PW WG CHANGE PROCEDURE <br /> YES = NO FYES.DATE (MI o C> <br /> p a ri�v OTHER <br /> w SOURCE OF DISCHARGTTT TANKS ONLYA:APACITY MATERIAL CAUSE($) <br /> = TANKLEAK UNKNOWN GAL = FIBERGLASS = OVERFILL RUPTURE/FAILURE <br /> a = PIPING LEAK AGE YRS STEEL O CORROSIONo UNKNOWN <br /> = OTHER = UNKNOWN = OTHER = SPILL = OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED SOILONLY = GROUNDWATER = DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY - <br /> 2y <br /> ¢� = SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) = CLEANUP IN PROGRESS= SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> y � NO ACTION TAKEN 0 POST CLEANUP MONITORMIG IN PROGRESS = NO FUNDS AVAILABLE TO PROCEED = EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> 3 z4 = CAPSITE(CD) F—] EXCAVATE a DISPOSE(ED) = REMOVE FREE PRODUCT(FP) ENHANCED BO DEGRADATION(IT) <br /> = CONTAINMENT 13ARRIER ICE) = EXCAVATE&TREAT(ET) = PUMP&TREAT GROUNDWATER(GT) = REPLACESUPPLY(RS) <br /> = TREATMENTAT HOOKUP(I" = NOACTIONREOUIRED(NA) = OTHER(07) <br /> r� ( 11 <br /> �1;11 w�C. �'^`< KwuJo,L <br /> i <br /> i <br /> KS�¢I� <br />