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9y- v�� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> �yu�( REPORT BEEN FILED? I HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE YES NO ❑VES ❑ NO DISTRIBUTION SHOWN ON THE INSTR <br /> VCT104SHEFT ON THEE KPAGE OF THIS EORt _ <br /> RE RT ATE CASE• �`���(� <br /> u Y SIGNED. DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ( / <br /> m <br /> w REPRESENTING ❑ OWNERXOPERATOR ❑ REG NALBOARO COMPANY OR AGENCY NAME <br /> ¢ LOCALAGENCY ❑ OTHER S <br /> S ADDRESS <br /> 0 . �QY TE 3 8 <br /> Fzp <br /> w NAMET T SON <br /> u Qy <br /> � PHONE9 <br /> OpD <br /> w I b ro ve STATE"�J <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESSI <br /> S5IREET T/I/a em S .v...��dY`y� —f�•�� <br /> N <br /> CROSS STREET <br /> N <br /> i w LOCALAGENCY AGENCY NAME CONTACT PERSON PHO <br /> Z� <br /> w REGIONAL BOARD PHONE <br /> u w ! 3 - o0-b01 <br /> m (0) NAME QUANTITY LOST(GALLONS) <br /> w 1 I � ❑ UNKNOWN <br /> a LLL <br /> �> m <br /> m ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OVAL <br /> aDATED HARGE BE D V/]Y Y ❑ TANK TEST ❑ TANK METHOD USED TO STOOP D SCHARGE(CHECK ALL THAT APPLY) <br /> aOTHER <br /> u I •Y �Y ❑ UNKNOWN ❑REMOVE CONTENTS�,ClO3E TANKb REMOVE REPAIR PIPING <br /> LUS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> O ❑ YES ❑ NO IF YES,DATE u MI D Y Y El REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> �a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> y O PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> u UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HECK ONE ONLY <br /> w Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> aF ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O m F-1 REMEDIATION PUN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(RP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ISff VLMR]I LETM8) <br /> a <br /> 0O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wF <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Fnlk#&i- si�� d s5�s Sswo,,L Li L i- be- Yawl rz <br /> .a7✓re r K4,1 n e. Y'e� D C-- <br /> 6" <br /> vlo r u <br /> H9 051 <br />