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IP IP UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />. EMERGENCY HAS STATE OFFICE OF EMERG CY SEF \ <br />REPORT BEEN FILED7 <br />I I YES 1-K10 I YES I r NO <br />', FOR LOCAL AGENCY USE ONLY •-: • <br />..LHEREBY CERTIFY- THAT I AM- A. DESIGNATED GOVERNMENT. EMPLOYEE. AND THAT: I HAVE <br />:REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />REPORT DATE CASES REALTH f COOE. / <br />7 - <br />"L";-. -Di 0 mi Ilimi OD, 5qyi 0 , SGNED <br />›- <br />NAME OF INDIVIDUAL FILING REPORT <br />DaA:t. I ry4.k. <br />PHONE <br />( <br />i — 1/0 0 .... /,..ts-/ <br />)2-711 x -13y <br />SIGNATURE i i <br />c <br />cs,._1 , 1442,,,6 <br />cl 111 I-- <br />FcS <br />REPRESENTING I OWNEFVOPERATOR I 1 REGIONAL BOARD <br />I 1 LOCAL AGENCY OTHER <br />COMPANY OR AGENCY NAME , 1 <br />SA -e- // 0, / c_omi9,4 y <br />a_ L u cc ADDRESS <br />/3 q 0 141,' I /0) 10415-5 —S TT qt <br />STAEET <br />C { Co fico ret A- c f ii-s—c) <br /> <br />STATE ZIP <br />w <br />cl'' <br />NAME <br />Sk_-ell 0: 1 C o , I UNKNOWN <br />CONTACT PERSON <br />0 ; CA. N. t. LA Ild1.14 i t5 t <br />PHONE i - vac) <br />( )02 7/q xe- 0.3 <br />?)2E u., ADDRESS Pr.s 4.19a 1./ o r Cr...,nocct CA- VT CITY STATE <br />67145-14 <br />ZIP <br />z o <br />FACILITY NAME (IF APPLICABLE) <br />S iVe. ti S-)-ct f,'0,... <br />OPERATOR <br />V; /11-(2,0._ War b y <br />PI-IONE <br />(;20.7) q 3I_37 <br />r- <br />..13 <br />Lil <br />ADDRESS <br />1 i 3 i-C kic.4-Ftr lac) QA, _CI-oe ki-o /A_ Son loolu; n_ .75-207 <br />STREET CITY COUNTY ZIP <br />i- <br />0 CROSS STREET TYPE OF AREA COMMERCIAL I I INDUSTRIAL I I RURAL <br />I I RESIDENTIAL I I OTHER <br />TYPE OF BUSINESS i to" RETAIL FUEL STATION <br />I I FARM I 1 OTHER <br />2 <br />Z. rIl ui <br />LOCAL AGENCY AGENCY NAME <br />SqA Jo4114 :1....ed, ritV;ram etvh,1 6,14-k. <br />CONTACT PERSON r,, , ro i, y <br />PHONE <br />()act) li6Z<-31t,lo <br />2 L" tuJ (3 a a 2 <br />REGIONAL BOARD <br />e r \ + - r a _ I V; I, 1 I -f• y <br />PHONE <br />( ) I SOURCEJCAUSE I DISCOVERY/ABATEMENd SUBSTANCES INVOLVED NAME QUANTITY LOST (GALLON ) <br />tcci-ktra 6ctso /1.k .e UWNOWN <br /> <br />I I UNKNOWN <br />DATE DISCOVERED <br />0 41.1 0 q 0 .1 .1'1— Di yl Y <br />HOW DISCOVERED I 1 INVENTORY CONTROL uasuRFACE MONITORING NUISANCE CONDITIONS <br />I TANK TEST I I TANK REMOVAL OTHER .. 0 : i 8, 0 ,-, ,1-1 <br />DATE DISCHARGE BEGAN <br />ml ml 01 01 'I 1 YI I lerUNKNOWN <br />METHOD USED TO STOP DISCHARGE (C CK ALL THAT APPLY) <br />I I REMOVE CONTENTS REPLACE TANK CLOSE TANK <br />HAS DISCHARGE BEEN STOPPED 7 <br />I 1 YES I I NO IF YES, DATEml 'I ml 01 01 VI <br />I I REPAIR TANK 7 REPAIR PIPING I CHANGE PROCEDURE <br />I I OTHER <br />SOURCE OF DISCHARGE <br />I I TANK LEAK UNKNOWN <br />TANKS ONLY/CAPACITY <br />.52 —5-/A I g - &NAL. <br />MATERIAL <br />I I FIBERCTUISS <br />CAUSE(S) <br />I I OVERFILL I I RUPTURE/FAILURE <br />1 PIPING LEAK AGE 3 / YRS 1 1.,(s-TEEL I I CORROSION I ler'rJWNOWN <br />I I OTHER I I UNKNOWN I I OTHER I I SPILL I I OTHER REMEDIAL I CURRENT I CASE I ACTION STATUS TYPE CHECK ONE ONLY <br />I. I UNDETERMINED ["SOIL ONLY I I GROUNDWATER I I DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br /> SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) 7 CLEANUP IN PROGRESS I 1 SIGNED OFF (CLEA P COMPLETED OR UNNECESSARY) <br />1 I NO ACTION TAKEN I POST CLEANUP MONITORING IN PROGRESS I 1 NO FUNDS AVAILABLE TO PROCEED EPIEVALUAT1NG CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />I CAP SITE (CD) I EXCAVATE & DISPOSE (ED) I I REMOVE FREE PRODUCT (FP) I ENHANCED SIC DEGRADATION (IT) <br />I I CONTAINMENT BARRIER (CB) 1 I EXCAVATE 8, TREAT (ET) I j PUMP S. TREAT GROUNDWATER (61) I I REPLACE SUPPLY (RS) <br />I I TREATMENT AT HOOKUP (HU) I I NO ACTION REQUIRED (NA) [VrOTHER (0T) TO bc.._ ete -1-e t wk ,` A 'e a ICOMMENTS I PC is " I 4 t ft.y rl A proyrts to rcpitttc_ +4,14s a n_ol. fra et s •i-cf- <br />„ --t-rA Ak-s tA, : i 1 13-c p la ...c,c1 i' r‘ A i' f cc , cn.-f - t 0 "._ <br />._,...,.