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_ 9 _ vim <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED? E] YES ❑ IHEREBYCERTIFYTHATI.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT(pMTE/ 6Y CASES .SIGNED SATE . <br /> NAME OF INDIVIDUAL FILING REPORT PHONESIGNATURE <br /> S ) 'fb��Y6 ' <br /> M REPR ENTING ❑ OWNERK)PERA R ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> SDg.LOCAL AGENCY ❑ OTHER <br /> a ADDRESS ��' ••• <br /> Ci9 ATE 9sao <br /> w Np <br /> NAME CONTACT PERSON PHONE <br /> M11m iw Qi UNKNOWN 06 <br /> U❑ <br /> ADDRESS <br /> P. o. gax 3!0 G� 4sa�7 <br /> STREET CRY STATE IP <br /> FA IL NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> s c.- s,CITY NTY qua <br /> yCROSS STREET <br /> i LOCALAGENCY AGENCY NAME CONT R e PHONE <br /> w saw "e E td o� X68 3 b <br /> w a REGIONAL BOARD u PHONE <br /> as <br /> w (1) NAME OUANTITY LOST(GALLONS) <br /> �XIO <br /> a UNKNOWN <br /> m <br /> UNKNOWN <br /> Z DATE DISCOVERED —/,I <br /> �/J 9 HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> o i Y Y ❑ TANK LEST TANK REMOVAL ❑ OTHER <br /> METHOD USED TO STOP <br /> R (CHECK ALL THAT <br /> m DATE DISCHARGE BEGAN UNKNOWN w Yl RE MOVE CONTENTS ISCHACLOSE TANKS REMOVE PPLID❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? `1',16, <br /> ❑REPAIR TANK ❑CLOSE TANK A FILL IN PLACE ❑CHANGE PROCEDURE <br /> 1-1 <br /> p YES ❑ NO IF YES,DATE OM 6 DD •7 [D REPLACE TANK ❑ OTHER <br /> V DISCHARGE CAUSES) <br /> as TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> �U ❑ PIPING LEAK ❑ OTHER CORROSION ❑ UNKNOWN ❑ OTHER " <br /> ww CRECKONEONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK <br /> ///ONE ONLY <br /> wZ Iyl NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION �1 <br /> jy LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS _ <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDBIOOEGRADATION(IT) <br /> J IYEe,EFfUR�El.V81 <br /> a p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wr <br /> as ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑+ TREATMEy/(aNy.T�ATHOOKUP(HU) E::] VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) asgogs // , <br /> + <br /> N9C65IMP& <br />