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922- � l <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ORLO IT USE ONLY <br /> {/- REPORT BEEN FILED7 1HEREBYCE FY IAT <br /> HAVEJ�I TR,9UTED THIS INF ATION ACCORDING TOT <br /> ❑ YES ❑J NO dVES ❑ NO yy Q <br /> DISTH l9 ON NON N ION EBACK PAG FTHISF M <br /> REPORT DATE Q CASE& e? <br /> O ZM Z o -I �Y VZD(a� N ATE` <br /> NAME OF INDIVIDUAL FILING REPORT PHONE I SIGNATURE <br /> MMS; [ kg_61 o 13101 7 ZGv9 <br /> REPRESENTING Yf OWNERIOPERATOR ❑ REGIONAL BOARD COMPANYOR AGENCYNAME <br /> S ❑ LOCAL AGENCY ❑ OTHER pie <br /> tE ADDRESS <br /> Iwl�tr rY✓1 F[f /`,��sJ'•/�J <br /> I�S Cm C4 BTATE 90101 <br /> IIP <br /> w NAMEPHONE <br /> p-1 Agcv oDIUNKNOWN MAZL*jgNL&A0 <br /> (310)4x7 <br /> g ADDRESS 4nCA <br /> 0 1O / <br /> Q0CITY <br /> •tet•'�/GLti'R G� W��\t V/ BTATE_N <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> At 449,3 f � R • v <br /> Q AO/DJR�EBS Cr f^ I� /iJ nZ <br /> w ✓ lam cel VAEET J CRY COVNtY '✓Li/IP <br /> y CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w� aAr1 o Icr DooW 1Lr;,p (Zoq 46 <br /> ww REGIONAL BOARD PHONE <br /> RVIefrb,kQt j JeA 440: 0 M1LLyIe- (91b13r.r•57� <br /> y (11 NAME QUANTITY LOST(GALLONS) <br /> a> S-t o ❑ UNKNOWN \(� <br /> �O (2) /�1J <br /> rn ❑ UNKNOWN y\1V• <br /> �- DATE DISCOVERED HOW DISCOVERED <br /> i p ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> pM ?-u l 4 -1 .1 ol Yl ZY ❑ TANK TEST ❑ TANKREMOVAL IRr OTHER <br /> m DATE DISCHARGE BEGAN ^ ' METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APS <br /> W � IY [� ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 1 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE 4 CHANGE PROCEDURE <br /> N f rt <br /> 0 ❑V YES E] NO IF VES,DATE Y ❑REPLACE TANK OTHER (NVVyL <br /> M M D Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL y� <br /> O ❑ PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN O ,/THER eLAW� <br /> HY1 <br /> ww CHECKONEONLY '�W <br /> FIeE epr, rA Mk4nL_ D21ku�1 sv , <br /> F-1UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS FIAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> ,w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMDTED ❑ POLLUTION CHARACTERIZATION <br /> E ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O REMEDATION PLAN CASE CLOSED COMPLETED OR <br /> ❑ UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> tiffI fOle 7` <br /> wQ ❑ CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT <br /> pBARpRIIER(CB) E:] NO ACTION REO�UIpflE.D'(NA)���❑GTR,EAT�MENT'A,IT^H�O�OKUyP�(H�U�) �/❑�V,E�NT/S�O�IL�(VS) n,I /,I, <br /> TF "AR_ Fa::... VOTHER(OT) I.1�/ VeeL' DWu1 (./Kl�•K✓ IIYTlJ rll[J�IYI 0�+�7�1 v <br /> z <br /> Gefl &GAMOii SM0 40 69b, 02. 1.O;F;' I S 0 Qp13L0"`l <br /> FEB 7. � W2 <br /> hLALih <br /> I esc os lasm <br />