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7y us 3 <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 ffl ND REPORT BEEN FILED? ❑ YES ❑ NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> --- DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE r CASE• <br /> wo .1 0 J Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING q PORT PHONE SIGNATURE <br /> (2-04 4 6Y� <br /> w <br /> RE;?Eo ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME a� <br /> S LOCAL AGENCY ❑ OTHER {� 3 00. � ��Lh%'(fk IWnn/!W/ /'� <br /> ADDRESS CC/�'� !� <br /> 3TREU-Sg rr J� C" SAC* STATE " 4 / <br /> w NA E CONTACT PERSON /� PHHONE V <br /> z Q r fall ❑ UNKNOWN (1/ . (n/ r / r {o hl 51 O -6 7a6 <br /> H y ADDRESS <br /> w <br /> STREET C" dLIM STATE ZIP <br /> FACILITY NAME OFAPPLICABLE) OPERATOR PHONE 71 <br /> a ADDRESS dI <br /> w / `�- STREET ZIP <br /> N <br /> CRO STREET <br /> O LOCAL AGENI AGENCY NAME CONTACTPERSON PHONE <br /> zy � O <br /> w 0 . 6_ ,rem nom. nor k rim c�—�-, <br /> w. REGIONAL BOARD PHONE <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> O <br /> 1NKNOWN <br /> z (Z) <br /> 7- <br /> x ❑ UNKNOWN <br /> Z DATE DISCOVEREDHOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E:] NUISANCE CONDITIONS <br /> p MI 0. o v Y ❑ TANK TEST [2-'TANK REMOVAL ❑ OTHER <br /> aDATE DISCHARGE BEdAN METHOD USED TO STOP DISCHPOE ALL THAT APPLY) <br /> 52"UUNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M d D Y Y <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE <br /> C, ❑ VES ❑ NO IF YES,DATE M 1 D Y Y ❑REPLACE TANK ❑OTHER <br /> 7SOURC DISCHARGE Aq CAUSE(S) <br /> a� TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> O PIPING LEAK ❑ OTHER 52--CDORROSION ❑ UNKNOWN ❑ OTHER <br /> ww CHECK0 ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> rL°� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> W;! ❑ LEAK BEING CONFIRMED dREUMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ R 'v^' <br /> O <br /> REMEDIATION PLAN ❑ CASE CLOSED COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY V <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT OFF) ❑ ENHANCED BIODEGRADATION(IT) <br /> j z Is3Av.[wROE" <br /> -OO ❑ CAP SITE(CO) ❑ EXCAVATEB TREAT(ET) E:] PUMP6 TREATGROUNOWATER fG1t❑ REPLACE SUPPLY(RS) (� <br /> w F <br /> V ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> W G aseosn.o A�- r /w n awl bj *K-4 T?ru pia� <br /> HSC OS Ib90I <br />