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_ 0 - u,ia <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> VES 9§�-NO <br /> REPORT BEEN FILED? E] YES K NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE i <br /> D M SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN TURE <br /> vLd 644inAvv 0 3 <br /> w <br /> ❑ pWNERN <br /> REPRESENTING PERATO <br /> 8 R ❑ REGIONAL BOARD COM/P�A OR KilENCY NAME <br /> m M LOCAL AGENCY ❑ OTHER '(pr'� (4J <br /> a ADDRESS j/{/.(-/Ll A /�P, "r <br /> CITY WAW �p <br /> NAME CONTACT PERSON PHONE <br /> i¢ Q (,LJ/Ci✓ ❑ UNKNOWN <br /> y <br /> m ADDRESS , /4/S qL ^U 3 <br /> SE <br /> P <br /> FACILITY NAME(IF APPLIOA ILq OPERATOR PHONE <br /> /�►- is Avty �o d A 1aU.l (so 9�FP- 03 <br /> ADDRESS YV6 2 <br /> / J /7cJ�.0 JQQ 9v1 h INI� ,J <br /> w 0 E!/N/do�'L srBEET DRY couxrrZIP <br /> m CROSS STREET <br /> LOCALAGENCV AGENCY NAME ODNTACTPERSON PHONE <br /> i <br /> m ( O <br /> Z91w <br /> w g REGIONAL BOARD PHONE <br /> y p) NAME OUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Du O D DY Dr ❑ TANK TEST TANK REMOVAL E] OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS DC CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M D Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> o ® VES ❑ NO IF VES,DATE u If D '10 <br /> r ❑REPLACE TANK ❑ OTHER <br /> 'a SOURCE OF DISCHARGE CAUSE(S) <br /> TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> m n CHECK ONE ONLY <br /> ❑ UNDETERMINED rX SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> wwm ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O cw] REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> PEE MGII <br /> M7` <br /> og F-1CAP SITE(CO) ❑ EXCAVATES TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GIT) REPLACE SUPPLY IRS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL NS) <br /> m /01D r <br /> ❑ VACUUM EXTRACT Nq OTHER(OT) TI^i1�1 .� /IHnil Q(Zle <br /> +rfLY AFL vcd 7tl�L 7�vrl ru r�+C 16 <br /> C o y� 7�7►i►sa. /Zi rry�. <br /> 3 <br /> N9D 6518'Ph <br />