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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES •FOO LOCAL'AGENCY USE ONLY <br /> El YES dNp REPORT BEEN FILED? E] YES ❑ NO IHEREBY CEH(1FYTHATt HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> P- <br /> �f CASE t L / <br /> O (oM 4 0 CI v SGx u ldF4 O <br /> NAME OF INDIVIDUAL FILING REPORTDA <br /> PHONE NA <br /> IE <br /> REPRESENTING <br /> OWNERrOPERATOR ❑ REGX)NALBOARD COMPANYORAGENCYNA <br /> S WL LOCAL AGENCY ❑ OTHER <br /> ¢ ADDRESS <br /> 304 F- WdoCr `TTAtrd Ro7r Z,'f k4o CA <br /> cm � srATE <br /> ZIP <br /> w NAME Q 1 ' CONTACT PERSON PHONE <br /> iQ TTl J 40�KC ❑ UNKNOWN K 7vod- <br /> os <br /> r (ZOO) <br /> w y ADDRESS <br /> w <br /> STREET Cm STATE iP <br /> Z FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> aADDRESS ( / <br /> s 1325 C)or('GI � o��otA1 tlL1C San.S titK 453}� <br /> yCROSS STREET yJ IP <br /> MA <br /> z LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w Soo uiLa Ce (EAav �{I�l� .)ctrl �os�n tok4 (2ctt)1{lo$-o33S <br /> w REGIONALBOARD PHONE <br /> as <br /> w (T) NAME QUANTITY LOST(GALLONS) <br /> U <br /> D <br /> F 0 (� ( UNKNOWN <br /> m5 m <br /> N <br /> ❑ UNKNOWN <br /> Z <br /> DATE <br /> II DISCOVERED (� `7- HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Pd 0 9 r T r ❑ TANK TEST TANK REMOVAL E:] OTHER <br /> Q DATE DISCHARGE BEGAN 1�I METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M o Y r ao{ UNKNOWN E]REMOVE CONTENTS 17� CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED T E:]REPAIR TANK '❑CLOSE TANK a FILL IN PLACE ❑CHANGE PROCEDURE <br /> S2 150 YES ❑ NO IF YES,DATE V Z Y TY ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> �� ❑ PIPING LEAK YYY--❑iii"' OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> yw PQ <br /> CHECKONEONLY <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 SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jN ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O O REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONLS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> IS�Bvxw�PETATaI <br /> 5 ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT <br /> (ET) ❑ PUMP 8 TREAT GROUNDWATER(07)❑ REPLACE SUPPLY(RS) <br /> wa ❑ CONTAINMENT BARRIER(CB) NOACTK)NREOUIRED <br /> ¢ ❑ (NA) ❑ TREATMENT AT HOOKUP(HU) E::] VENT SOIL(VS) <br /> ED VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> h �1u�t-he,1. m%dmA"Ia'� s_a'cs_%tA%c. -t wtf) 61c, "Ufrd do <br /> w �NC fp,AA-p <br /> RSC OS(S'9N <br />