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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)If CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL-AGENCY USE ONLY <br /> . <br /> YES NO <br /> REPORT BEEN FILED T VES Q NO I HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN IXJ THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTOATE CASE <br /> Dq M D 4• 1 p v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPOR PHONE SIGNATURE <br /> m - <br /> REPRESENTING 71 OWNERIOPERAfdfi REGIONAL BOARD COMPANyY OR AGENCY NAME �� J D <br /> S LOCALAGENCY Q OTHER • / <br /> S J �-oe <br /> ADDRESS <br /> erReEr cm &TATE ZIP <br /> w NAME /I COONNT�A�CT/,/APERSON PHONE <br /> Ad <br /> Z Q I �J/IS 1 S ,.[:j UNKNOWN f i.C"�'6 / /I_TS/G <br /> y ADDRESS (/l �� C/�Y V-fO`�/ • _/ _• _ <br /> 313 3 / Y T/v`J <br /> sr cm &TATE <br /> FACILITY NAME(IF APPLICABLE) ` OPERATOR PHONE <br /> a ADDRESS J (�//�1 s't0 c Z W✓" • / �� <br /> •313 .3 Ad fir r t RRA Dm CWNTY IP <br /> CROSS STREET <br /> Ch epo Ke e- <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 45a4La (rotiYt6g 3 <br /> I REGIQNAL BOARD v PHONE <br /> Lp L3 <br /> m (1) D NAME QUANTITY LOST(GALLONS) <br /> U <br /> O otI f j "�'u.Q/�.� 0 UNKNOWN <br /> w <br /> a� <br /> �o <br /> y z <br /> O UNKNOWN (� <br /> i DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL � SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> {/ 9 Ov TANKTEST F7 TANK REMOVAL O OTHER <br /> BEGAN r <br /> m DATE DISCHARGE BMMETHHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN KREMOVECONTENTS I J(I CLOSE TANK&REMOVE REPAIR PIPING [IUB <br /> M d D Y T1 <br /> HAS DISCHARGE BEEN STOPPED i 0 REPAIR TANK O CLOSE TANK&FILL IN PUCE I]CHANGE PROCEDURE O <br /> D YES � NO IF YES,DATE QM q a D qr gv E]REPLACE TANK OTHER <br /> RCE OF DISCHARGE CAUSE(S) <br /> j TANK LEAK UNKNOWN O OVERFILL O RUPTUREIFAILURE O SPILL <br /> y0 PIPING LEAK O OTHER 0 CORROSION UNKNOWN O OTHER <br /> ww CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ �NO ACTION TAKEN r7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> MN O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PUN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) Ej REMOVE FREE PRODUCT(FP) ENHANCED BID DEGRADATION(IT) <br /> P�era•rw oeT.Mm <br /> a CAP SITE(CD) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wp <br /> F <br /> wa CONTAINMENT BARRIER(CB) F-1NO ACTION REQUIRED(NA) E] TREATMENT AT HOOKUP(HU) E:] VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> 92 <br /> z <br />