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0 9Ll- v3G1 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED 7 <br />FOR LOCAL AGENCY USE ONLY <br />1-1 YES NO ❑ YES 1O <br />1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THE INSTRUCT SHEETON CK PAGE OF THIS FORM <br />REPORT DATE <br />CASEi <br />Z <br />1 <br />SIGNED. DATE <br />M J v <br />NAME OF INDIVIDUAL FILING REPOR <br />PHONE <br />SIGNATURE <br />m <br />� Ifa <br />(zc* I yl -0334i <br />w <br />REPRESENTI G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />SLOCAL <br />AGENCY ❑ OTHER <br />a <br />¢ <br />ADDRESS ��, //,. <br />`}v Lf <br />S N' SG'�) I <br />RTmu O G u ST <br />c, C `n �TE(f <br />J <br />ZQ <br />NAME �A/j 1 % <br />I-� a� MIL I'I Hl l.O ❑UNKNOWN <br />CONTA^CTPERRSON 4 <br />(.✓04- �e✓� U ) I� <br />PHONE y9�y <br />( )Sr/�-/GO/ <br />a n <br />w <br />¢ <br />ADDRESS <br />2o S. L yS36 <br />Z 6 <br />l STREET CT' .( CJ•/ STATE 1. S 21P <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR n PHONE <br />Ml 4� L a <br />� <br />�g JJ � (Z01) 71S -y7-67 <br />o <br />s <br />ADDRESS <br />z� /i / / , <br />w <br />S 4TREET ><xJ�7�-�" cm C7 /1 COUNTY ZIP <br />m <br />CROSS STREET <br />2.nJ S� <br />i <br />LOCALAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />w <br />REGIONAL BOARD <br />PHONE <br />GI- c4a <br />y <br />(1) NAME QUANTITY LOST(GALL <br />0 <br />Z > <br />? SC , UNKNOWN <br />C <br />m i <br />(2) <br />�- <br />N <br />o UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />7 <br />'/x C/Y <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />�/MI Out l o <br />m <br />a <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />¢ <br />UNKNOWN <br />MI MI DI 01 YJ Y <br />E] REMOVE CONTENTS LOSE TANK 8 REMOVE ❑REPAIR PIPING <br />W <br />❑ REPAIR TANK ❑ CLOSE TANK d FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />L6 "S ❑ NO IF YES, DATE <br />❑ REPLACE TANK ❑ OTHER <br />M uI D Y Y <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />¢� <br />Ll TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE E:] SPILL <br />w0 <br />❑ PIPING LEAK F-1 OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />yw6 <br />CHECK ON <br />O <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w� <br />❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />w <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EX VATE d DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />ISP ROPRIAFEA <br />ooO <br />❑ CAP SITE (CD) E%CAVATEB TREAT (ET) ❑ PUMPd TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RST <br />wa <br />❑ CONTAINMENT BARRIER (CS) ❑ NO ACTION REOUIRED INA) ❑ TREATMENTATHOOKUP(HU) ❑ VENTSOIL(VS) <br />❑ VACUUM EXT/RACY (VE) ❑ OTHER (OT) <br />�v/�f�C/ J)/I✓t�S��/9 cin /✓i��� �e ,12�p!/i/Lo f� <br />z <br />o <br />L. <br />74 C 1C Jaz .? 7 f ©n r�+i L•Lls 7�,:o A+ <br />7�C/M/�✓!C <br />O <br />NSC 0.s (fl O) <br />