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r.t � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERV FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YE5 NO ❑YES LJ NO I HEREBY CERTIFY.THAT i AM A-DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT-TO 5ECTION 25180.7 OF <br /> REPORTOATE CASEa THE THAND AFTYCQDV <br /> D M MAyj ) y SiaNE TE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGN UAE <br /> 1&�3 y z-0 <br /> m <br /> o REPRES ING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANYOR ENCY NAME <br /> cr p LOCAL AGENCY ❑ OTHER S J'( <br /> a <br /> ¢ ADDRESS <br /> �� L7 Lan i STREETE ZIP <br /> uJ NAME CO TACTPERSON PHONE <br /> � pp^^ ,,/ / <br /> ADDRESS t -644. o ❑ UNKNOWN ![ <br /> ATE ( �'"" <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRES <br /> � n <br /> rrry <br /> COUNTY p <br /> rn CROSS STREET TYPE OF AREA ❑COMMERCIAL DUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> Gjy`,� ❑RESIDENTIAL ❑OTHER ❑ FARM ElOTHER <br /> LOCALAGENCY ,/ '/ AGENCY NAME CONTACTPERSOK PHONE <br /> w REGIONAL BOARD PHONE <br /> CL !! <br /> � l } <br /> (a {11 NAME QUANTITY LOST(GALLON ) <br /> TP1 _ � 'GALLON <br /> u (2) <br /> N <br /> UNKNOWN <br /> Lu <br /> DATE DISCO ED HOWDISCOVERED Q INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN I /, METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D D v Y L E UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK Ft�CLOSE TANK <br /> HAS DI ARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES,DATE �M C- M 7, o YJ T Y ❑ OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSES) <br /> ❑ TANK LEAK ZUNKNOWN /� j2nd GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE _YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> U ❑ UNDETERMINED OIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> 2 N <br /> ¢a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> S I <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 /> o O ❑ CAP SITE(CD) F-] EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> m� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> c2[�r� <br /> / Q/L(,���i /� �'VY1J TP� ' /l ��.'Y�/ / IS/�.T'C/ J / AJ • �� J-L� ��GY'�-C_.�/�r�'l LL"�/��ti"l� <br /> l �. �e �ClI~�^� t`�u ���-� ��ti f✓✓✓��w�� !��,� •�'.�yG�c� ! Y�,�:�yl-�-ft' <br /> 11sc05µ47) <br />