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UNDERGROUND STORAGE TI, _ UNAUTHORIZED RELEASE (LEAK) / C rAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FLED' <br />n YES NO I .I YES cZ NO <br />FOR LOCAL AGENCY USE ONLY <br />I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />REPORTED THIS INFORMATION TO LOCAL OFFOIALS PURSUANT TO S -DON 25180.7 OF <br />REPORT DATE CASES OO <br /> <br />THEa <br />( <br />AND S <br />DATE <br />1 NAME OF ,NO VIOUAL FLING REPORT <br />1 ),- • A _ctr-:-Y c;:( PY • = <br />PHONE <br />( 26'9) q 6.3 -3 c 7 1 6., .S'' <br />I SIGNAT E <br />. I La ,-- = <br />0 <br />REP RES NTING 7 OWNER/OPERATOR 1 I REGIONAL BOARD <br />LOC OTHER AL AGENCY I I OER <br />COMPANY OR AGENCY NAME <br />SA A.) r JO !i i r 14.-4(... ill ,4 _P t _ a. La cc• <br />a= 1 - 1 /9?-.CE-Ttr,/ A 1) E <br />STIREET <br />ADDRESS Se2tncel, <br />57Z-15`.7r i ..9- <br /> <br /> <br />STATE -ZIP <br />Lu <br />kn cc. <br />NAME <br />be Ai/J/1 crit-72 c.),(.) E-R_ I UNKNOWN <br />CONTACT PERSON <br />74yyt..._------- <br />PHONE <br />( ?/ Y5 Li, 2 q- 3(--,k, <br />Lu cc <br />ADDRESS <br />ini ‘G), S7-7 1.7._ 5773E_ <br />C-7/e/4/UC•C- Cri:14- <br />CRY STATE <br />q '7.74-*'?"- <br />2IP <br />FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br />Q <br />I- <br />..i., <br />La <br />ADDRESS -...-- <br />.7 & 0 ,C) A.). / HCRAJ I-ri"-) --ROE: ti-10721070J <br />STREET CfTY COUNTY ZIP <br />5 CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL RURAL <br />I I RESCENTIAL I j OTHER <br />TYPE OF BUSINESS E RETAIL FUEL STATION <br />[ I FARM OTHER <br />c2 <br />'' a) <br />LOCAL AGENCY AGENCY NAME <br />I C \_oAQL.1 1 NI 14 (4,r2_11c FS <br />CONTACT PERSON <br />(Th5e-71 '..--c- EY <br />PHONE <br />( '`-', ) (46,-,-37,/,' ? <br />Iti LI REGIONAL BOARD <br />C_..,. (32 OA 0 72; /e i) r? ri Cie!--(7-s_ <br />Ct)7) '7-2 <br />PHONE <br />( ) <br />0 Lu cm 0 ui <br />(1) NAME QUANTITY LOST (GALLONS) <br />GR -----":"(..!(--/ Ale pa UNKNOWN > , 5 ch > (2) ca , D = cn UNKNOWN <br />1- z La M La <br />DATE DISCOVERED <br />cm' Ad 0 SI RI Y 9 01 <br />HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING [ I NUISANCE CONDITIONS <br />TANK TEST OTHER REMOVAL OER <br />i-- cc <br />1.1.1 <br />DATE DATE DISCHARGE BEGAN <br />MI MI ol Di yl yi rx UNKNOWN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />REMOVE CONTENTS REPLACE TANK CLOSE TANK <br />> § <br />5 <br />HAS DISCHARGE BEEN STOPPED? <br />1 1 YES 7 NC IF YES,DATE .1 MI 01 y1 y D I <br />REPAIR TANK REPAIR PPING [ I CHANGE PROCEDURE <br />r-g OTHER afin et Iti_ ftt_... SOURCE/CAUSE I SOURCE OF DISCHARGE <br />I I TANK LEAN , UNKNOWN <br />TANKS ONLY/CAPACITY MATERIAL <br />/CCO MOO, (ZOO GAL. FIBERGLASS r <br />CAUSE(S) <br />OVERFLL RUPTURE/FAILURE <br />r7 PIPING LEAK AGE YRS V14--STEEL CORROSION iej.. UNKNOWN <br />I I OTHER I-1 UNKNOWN t 1 OTHER SPILL [ I OTHER <br />Lu Lu CHECK ONE ONLY <br />i j UNDETERMINED 51 SOIL ONLY I I GROUNDWATER [ I DRINKING WATER - (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CURRENT 1 STATUS CHECK ONE ONLY . <br />SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS fl SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />I I NO ACTION TAKEN POST CLEANUP MONITORING IN PROGRESS 7 NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br />5 0 <br />W cc <br />4 z <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />I I CAP SITE (CD) EXCAVATE& DISPOSE (ED) REMOVE FREE PRODUCT (FP) fl ENHANCED BIO DEGRADATION (II) <br />I I CONTAINMENT BARRIER (CB) E EXCAVATE & TREAT (ET) fl PUMP & TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />I I TREATMENT AT HOOKUP (HU) 7 NO ACTION REQUIRED (NA) 7 OTHER (0T) <br />cr) , z <br />LA' 3 . <br />-in <br /> <br />- - P. t i ler-Hex- 5 (TE--- / 9 55e5S.V.i ati7- 1,0 i t_e_ 2-,;,6--. ' Ec..)(_) 02e.-t. I)&/cR/t-, r iti -6- -,-,,,--e-- Ai/ f - 7- - u le ic <br />f <br />4` £T i1 ,!;, Con.tr-7>A4 /77 0,...1 , 4 5 RE-e.?u 1 I ze-.) &/ Tilt-- r4-PAecp/e114r - /9e-ref;v c/ . <br />— <br /> <br />/1-1/5 C/r-g- 6 4- <br />Q ( <br />6 Pie0 tvI 77./t-- 7-7-7,c4A,7-0,0. ,t4,77---7Z-- S ?es' ja-ii-( . <br />cCV L)2-\ <br /> IISC OS (4.67)