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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED i ❑ YES ❑ <br /> YES NO NO 1 HEREBY CERfIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE CASES - <br /> ���.- <br /> M & u r SIGNED DATE <br /> NAME OFINDIVIDUALFILING REPORT PHONE SIGNATU/R�E <br /> m (.�-G✓o/ o Ti ( <br /> w REPRES ❑ OWNERIOPERATOR ❑ REGIONAL BOARD <br /> COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER a,77o,i /u61<< lle lfti $evetc as <br /> ADDRESS <br /> S/v ck 1.1 CA ysao y <br /> SRIEET CRr (KATE ZIP <br /> j NAME <br /> iQ LU ��CL�7L1-e�/TO li CO/NTAICTPERSON PHONE <br /> ❑ UNKNOWN ( ^Ap) <br /> Q -�O7' c <br /> y a ADDRESS <br /> a/ o/ E. Clza.{tv (a>u� S�ack6cn C9 Qsa06 <br /> eTREET CITY � n� STATE mp <br /> ��(� -7 <br /> O FACILITY NAME(IF <br /> IL-0 APPLICABLE) <br /> Ll/ lee,- � �1 o 6,l OPERATOR1"-e SN& �� PHONE <br /> (y� t 79 01/ <br /> UADDRESS !(N• GR GI CAS Lid-1 CLQ (- S�LJ�`�o H C / <br /> STREET CRY ZIP <br /> lu <br /> -y CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z y <br /> z / <br /> W <br /> 2.1 REGIONAL BOARD /PHONE <br /> H (1) NAME QUANTITY LOST(GALLONS) <br /> wo / � <br /> ye j Cd G S C) 10",ti.e NKNOWN <br /> m - ❑ UNKNOWN <br /> DATE DISCOVERED (y HOW DISCOVERED ❑ I TORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i U P/_M v o ( r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> 13 t <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M o v r UNXNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISC E BEEN STOPPED 1 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE �• <br /> Q VES ❑ NO IF YES,DATE .1 MI DI J Yl Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> w� ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ywa CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> wy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ <br /> REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ ❑N(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> Pill ROK R LATE A) <br /> az <br /> ❑ CAP SITE(CO) ❑ E%CAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w0 <br /> ¢a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED MAI ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z <br /> SO <br /> 5/ �ssPsr.tio.Ly �,��G/ ! . <br /> u AL.'( ef-c w �4 o a/ck-., � �y 1&4 � <br /> fyleud of of "IA-ow 6 ! G <br /> MSC OSI <br />