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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV DES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED Y I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES dNO ❑ YES L"j NO DISTRIBUTION SHOWN ON THE INSTRUC N SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASEA I I'4 r� <br /> u u v SX:NED (]DATE <br /> NAME OF INDIVIDUAL FILING REPORT . PHONE SIGNATURE f <br /> > Ma ar area r[a (DA NIA-34" <br /> REPFIESEN71 OWNE ERATOR REGIONAL BOARD COMPANY OR AGENCY NAE <br /> dOCAL AGENCY ❑ OTHER nJA�u[n Laa n. Publ(4 tea(-lhSerul�<.S <br /> S Iron <br /> ADDRESS CA+ q S oy <br /> vi Cm STATE ZIP <br /> wNAME [� CONTACTPERSON PHONE <br /> /��/ <br /> m AL Q\ John E] UNKNOWN TMlp-1--I1S <br /> In <br /> n ADDRESS <br /> °mc-�'}a'� Coto <br /> Cott 9Sa <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> = &V Le-voJ-d (►e Serul yoq >q44-X7)5 <br /> o <br /> ADDRESS <br /> at 51 C,0L h-6G 4A..6 `i4mt4v,. San ,r I^ 0N l <br /> w $fgEET cm couNn ^ <br /> m CROSS STREET <br /> LOCALA CY A Y AME CONTACT PERSON PHONE <br /> pw �L�u(n CouV. a rt-kalfti• r(0 (a�) X834 9 <br /> w o ronrY. <br /> w 0 REGIONAL BOARD PHONE <br /> ` GVRuJC�CB �1[ulx�-h <br /> a55-3133 <br /> t NAME QUANTITY LOST(GALLONS) <br /> w V n f a l l re-- <br /> (2) <br /> �_ �GNKNOWN <br /> a 3 NNJJ <br /> m ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O H W V oI o $r S'Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> L�/<NKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> W <br /> ml 01 Y1 Y <br /> 8 HAS DISCHARGE BEEN STOPPED? REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES [:] NO IF YES,DATE 0.1 <br /> u i C). ❑REPLACE TANK aOTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> �+O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ywa CHECKONEONLY <br /> OJUNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> w� NO ACTION TAKEN F-1 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(RI) O ENHANCED BIODEGRADATION(IT) <br /> J I�yGR fO14fTNA1 <br /> < ❑ CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 00 <br /> wr <br /> ¢a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> S L te- ti\as been (o L&cp kr, to c-A-i "nd9.4w I ruJ-e-4 s ife Jx-f-L&Ls-e. <br /> �u r 1 he r n es 1-t�a t o Y. ar.�l rw-4 Y e-JL[a-1-r a+-. w A L L be. <br /> a <br />