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93 -1,� 7 <br />Mft Am — - <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINKIWPM <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED 7 <br />FOR LOCAL AGENCY USE ONLY �#' � d +. <br />1 HEREBY CERTIFY <br />❑ YES ❑ NO ❑ YES ❑ NO <br />THAT t HAVE DISTRIBUTED THIS INFORM IAY ACCbR IN E <br />DISTRIBUTION SHOWN ON THE INSTRUCTION S $Ra A Q{31TrIJIM. � <br />�'4, 'fi C A 1 <br />REPORT DATE <br />CASE a <br />r�i+ T <br />M Y <br />6- <br />I / <br />• ER M I F A -h-- ER <br />SIGNED pA _ <br />NAMEF IN UAL FILING REPORT \ <br />PHONE <br />SIGNAtbRE�� T <br />ca <br />qptont <br />to) <br />o <br />w <br />C - <br />Cc <br />REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD <br />❑ LOCAL AGENCY THER <br />COMPANY OR AGENCY,2;E <br />/ O <br />Q <br />ADDRESS <br />! CQ C r]©-'"'^^^^9�O" -6 ©, <br />7 <br />/ <br />STREET CITV <br />Y STATE ZIP <br />w <br />J#0�" <br />NAME <br />CONTACT PE ONco <br />PHONE <br />Z4le <br />UNKNOWN <br />O <br />cr a <br />w <br />w <br />ADDRESS <br />P © .Pox Co 3g c /'l l'l'O�—c�2 %/� 03 <br />� ✓ � �S/ V <br />STREET CITY STATE ZIP <br />FACIL NAM (IF APPLICABLE) <br />OPE ATOR <br />Z <br />T <br />�yP�HC(�ONE (/� <br />A/ <br />Q <br />L) <br />O <br />AD�RF65 • V V a Vt/G-1 G/�-�/ Li.� I7 "/ D <br />CTCA <br />/ <br />F <br />STREET f CITY COUNTY ZIp <br />y <br />CRO STREET <br />�ry <br />zLLJz <br />LOCAL AGENC <br />CON TPERSON <br />, <br />PHONE <br />w'4��AM(�r <br />��� C <br />w w <br />J O <br />REGIONAL B APHONE <br />t <br />a- Q <br />19b <br />^-' <br />U) <br />LIJ <br />o <br />(1) NAME QUANTITY LOST (GALLONS) <br />l�,� <br />a <br />O ❑ UNKNOWN <br />f- <br />m ° <br />z <br />(Z) <br />1 <br />❑ UNKNOWN � <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSU ACE NITORING ❑ ANCE CONDITIONS <br />/J� <br />MI �� Vol r y <br />❑ TANK TEST ❑ TANK REMOVAL THER ' V` <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />a <br />w <br />M JM o D Y v ❑ UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK 8 REMOVE ❑ REPAIR PIPING <br />REPAIR TANK ❑ CL A FILL I PLACE ❑CHANGE PRO DUKE <br />HAS DISCHA EEN STOP D 7 <br />U <br />o <br />�% <br />YES ❑ NO IF YES, DATE aM <br />REPLACE TANK OTHER C/ <br />MI o V o r r <br />SOURCE OF DISCHARGE <br />❑ TANK LEAK ❑ UNKNOWN <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br />❑ <br />U <br />F-] PIPING LEAK ❑ OTHER <br />❑ CORROSION ❑ UNKNOWN THER <br />Lu w <br />U) CL <br />CHECK ONE ONLY <br />U <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />wcn <br />Q <br />❑ NO ACTION TAKEN ❑ RY ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br />U N <br />RY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ LEAK BEING CONFIRMED ❑ ]iASECLOSED <br />❑ REMEDIATION PLAN (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />(SEE BACK FOR MTAIS) <br />a Z❑ <br />00 <br />CAP SITE (CD) F-1 EXCAVATE& TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />Lu <br />w a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO AC REQUIRED (NA) TREATMENT AT HOOKUP (HU) ❑ ENT SOIL (VS) <br />Q <br />❑ VACUUM EXTRACT (VE) OTHER (OT) <br />z <br />Q s o r e moi, v��' / _, kl t � I -I a l it err <br />Lu <br />1 �-�e__ Co �, �- ��Ks c�► erg o� <br />/� Ck44_W'-9-_ <br />HSC 0.5 (&WJ/\//nom <br />