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q1 - uqS <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 7 OYES ❑ NO HEREBY <br /> TR g TIONnSHOWN ON THE INSTRUCTION DISTRIBUTED <br /> IET ON THE BACK PAGES OF TH ISATION ACCORDING THE <br /> FORM <br /> REPORT DATE �j. CASE s _ _ _ c2.. <br /> M O 7 /V -SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> p <br /> w <br /> jFlEaRE�S22G/ <br /> ❑ OWNEWOPERATOR ❑ REOIONALBOARD COMPANYORAGENCYNAME <br /> SAL AGENCY ❑ OTHER <br /> ¢ ADDRESS ` `sy- S �h CIO <br /> IV N • San ✓AadL4m Of <br /> STRFEf Cm STATE ZIP <br /> j NAME Le�✓is CONTACT PERSON /PgHO�NE� <br /> w l/ ❑ UNKNOWN 04 ) 9YSl'S67 <br /> h g ADDRESSCff <br /> et S�CfS""'�, <br /> STATE ZIP, <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> <&Y-/ d F <br /> < ADDRESS <br /> g �Oa ti< <c /�ii,.,w �SyFac bv`vir Cat �s s <br /> 3TI1EEf Cm COUHfY P <br /> yCROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> Ca Z (2r�1 4�bcP'3 4 <br /> R ZONAL BOARD PHONE <br /> m (�) NAME QUANTITY LOST(GALLONS) <br /> w NKNOWN <br /> Q J <br /> UNKNOWN <br /> i DATE DISCOVERED Cep HOW DISCOVERED ❑ TORY CONTROL O SUBSURFACE MONITORING ❑ NUISANCECONDRIONS <br /> M 046 u o l r r E] TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M 0 Y Y <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IFYES.DATE M MI DI J Yl Y ❑REPLACE TANK E::]OTHER <br /> -3 SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK ❑ <br /> UNKNOWN ❑ OVERFILL ❑ RUP E/FAILURE O SPILL <br /> wO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN O OTHER <br /> w w CHECK ONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMRTED O POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEINGCONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY \ <br /> CHECK APPROPRIATE ACTON(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 7 e<c<iQ144TAYI <br /> ❑O <br /> QZ ❑ P SITE ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> wr <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �Gvrf�sr S!/i Qssers�Pv«f << // .ILO ~C 4P s tea. fo e�e.YGss..iw f(� oio7 +` <br /> /ac -0 s—�u la�RiP� <br /> �sc I.oI <br />