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PON, <br /> UNDERGROUND-STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED? - ��l OCALAGENGY USE ONLY <br /> ❑ <br /> YES <br /> NO ❑YESHEAE61(.CRT{fY <br /> HATA AM i4 D�$)C�fl{TkQ GOVRNMENf EMPLOYS AND THAT(.NAVE. <br /> REPORT DATE x c �RTE�?THIS IM TJON';,T LDCA QFFIC(AL$ PURSUANT TO;8FCTION... i.8 OF: <br /> CASaW a _ - T tIE AL CODE <br /> o y, y <br /> NAME OF INDIVIDUAL FILING REPORT tAr .., <br /> r' PHONE SIGNATURE <br /> REPRESE G ❑ OWNER/OPERATOR ❑ .REGIONAL BOARD COMPANY OR AGENCY NA <br /> p LOCAL AGENCY ❑' OTHER - _ - <br /> ¢ ADDRESS v'' r L 0IS I eC IGT J <br /> NAME carr In STATE Z�u� <br /> "J,, CONTACT PERSON <br /> t*A,rvl �Xiy L U = UNKNOWN <br /> PHONE- <br /> LL ADDRESS ❑ ll� �� 3��� <br /> Lu <br /> q <br /> ' STREET '/5- r <br /> FA <br /> CIL)TY NAME(IF APPLICABLE) BTaTE - <br /> -� OPERATOR PHONE <br /> o arMC.�` 1 �xQ.Gp <br /> q ADDRESS <br /> STREET' L' ,COUNTY) <br /> W CROSpo, <br /> REE? 't, Crry e % '/�� F a <br /> 4 TYPE OF AREA COMMERCIAL O INDUSTRA RURAL TYPE OF BUSINESS P <br /> we-{`S J , Ve A ❑RESIDENTIAL,❑OTHER RETAIL FUEL STATION <br /> LOCALAGENCY ❑ FARM ❑ OTHER <br /> w r AGENCY NAME CONTACT PERSON PHONE <br /> w UJ REGIONAL BOARD <br /> PHONELU jJ} <br /> NAME OUANTFTY LOST(GALLONS) ) <br /> (z) ECKUNKNOWN {k r <br /> Z HO <br /> DATE DISCOVERED L� UNKNOWN <br /> HOWDISCOVERED n INVcNORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUfSANCECONDfTIONS <br /> 1- TANK TEST TANK REMOVAL ❑ OTHER <br /> . <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL T WT'AF?PLY) I <br /> wM M .o .r n ' y y +�NKNOWN - ❑. REMOVE CONTENTS Q _REPLACE TANK GLOSE TANK <br /> 'HAS DISC H BEEN STOPPED? - _ e7 <br /> r i_ <br /> r �. ❑;REPAIR TANK REPAIR PIPING. <br /> ❑ ❑ GRANGE PROCEDURE <br /> o YES ❑ ND;IF YES,DATE s ❑ OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY <br /> D `y MATERIAL CAUSE(.) <br /> ❑ TANKLEAK UNKNOWN l Uf1Ul GAL ❑,FIBERGLASS <br /> ¢ ❑ PIPING LEAK AGE = YRS ­SEL ❑ OVERFILL ❑ RUPTURE/FAILURE +a <br /> ❑ OTHER UNKNOWN ' ElCORROSION . �1lf�NOWN <br /> Lu w CHECK ONE ONLY ❑ OTHER ❑� SPILL:3❑ OTHER <br /> v ❑ UNDETERMINED ❑�SOIL ONLY <br /> GROUNDWATER ❑ DRINKING WATER. (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Lu <br /> cz ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OFPROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP PLETED OR UNNECESSARY) <br /> v`� ❑ NO ACTION TAKEN ❑- POST CLEANUP MONITORING IN PROGRESS <br /> -❑-NO FUND'S AVAILABLE TO PROCEED ALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) Y r ` <br /> w O " ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP). ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(C8} ❑ EXCAVATE&TREAT(ET) % ❑ PUMP 8 TREAT GROUNDWATER(GT) s) <br /> ( T) ❑ REPLACE SUPPLY <br /> ❑ TREATMENT ATHOOKUP(Hu) ❑ NOACTIONREQUIRED(NA) ❑?OTHER(OT) <br /> Z t <br /> - HSCO54AS7) 1 I <br />