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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMEN ERVICES FOR LOCAL AGENCY USE ONLY <br /> �-�/ REPORTBEENFLED? I HEREBY CERTIFY THAT i AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> 71Lj YES ^0 ERGES ❑ NO REPORTED THIS:INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 26180.7 OF <br /> H AN <br /> m � �L�L� �S(' // 4[R✓{ I.THE <br /> REPORT DATE E# <br /> RDE /6"A.yDAT`E <br /> M OM <br /> NAME FINDIVIDUAL NG RE?QRPHONE Y -J .. <br /> t1 <br /> O RE�PRgE'�J,�,','',',u,'G OWNEWOPERAMR ❑ REGIONAL BOARD OOMnPANY OR AGENCY NAME {.� <br /> a LJ """�ACaENCY ❑ OTHER J CL P — /E <br /> ADDRESS Cf9„ N y 1 <br /> p, o �-bx aoo 9 �S�a�K OATS 6v P <br /> w NAMECONTACTPERSON PHONE / n <br /> as F oo ❑ UNKNOWN ��--++ n /N` o lye - 75 <br /> ADD SB 5a6OvAm STATE zip� <br /> ��/Iz� % 9 <br /> FACLI AME(F APPLICABLE) OPERATOR PHONE <br /> Q ds Ra ds l ) z <br /> ADDRESS S�a c�`�v ' - S7� q a a J <br /> ! O d � GIJQ��'}�CfJ'd KTY P <br /> US CROSS STREET <br /> reef <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> au6o P14 s - r r , Di d l✓s r� � �o�►Y6P-3 <br /> 3'4�f REGK)NAL BOA �. �OC � (HONE <br /> c ` <br /> i a I <br /> ur (t) NAME QUANTITY LOST(GALLONS) - <br /> a� <br /> fd <br /> �- ❑ <br /> UNKNOWN <br /> i DATE DISCOVERS ,/�/1/ ///� HOW DISCOVERED ❑ I NTORY CONTROL ❑ 9 RFACE MONITORING ❑ NUISANCEOONDMNS <br /> I u D M <br /> 41101 • Y `•• r ❑ TAW TEST �REMOVAL OTHER <br /> GATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THA PLY) <br /> �jppWN ❑ REMOVE CONTENTS ❑ REPLACE TANK OSE TANK <br /> QHASDISC Ml N GE BEEN STOPPED? Y / REPAIR TANK ❑ REPAIR PIPING ❑ CHANGEPROCEIX)RE <br /> 0 YES ❑ NO FYES,DATE /M OM 6. ✓p �V �/ v ❑ OTHER <br /> SOURCE?F,B,90HARGE CAUSE(S) <br /> Eq�TANK LEAK Q UNKNOWN ❑ OVERFLL ❑ RUP REFAILURE Q SPILL <br /> 1:1PIPINGLEAK F-1OTHER ❑ CORROSION MKNOWN ❑ OTHER <br /> CHECKONEONLY <br /> F ❑ UNDETERMINEDSOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK O NLY <br /> NOACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING NRO <br /> PROGRESS <br /> REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREEPRODLK:T(FP) ❑ ENHANCEDBIODEGRADATION(IT) <br /> eerxwno 7 <br /> �z PUMP GROUNDWATER REPLACE SUPPLY IRS) <br /> ❑ CPP SITE ICD) ❑ EXCAVATE&TREAT(ET) ❑ ❑ <br /> ❑ CONTAINMENT BARRIER(CB) ❑ AC TION REQUIRED(NA) �C T�RCEAT,MyE.N�T A�T�H'O�O(KUP(HU) ❑ VENTS00.(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) BOTHER(On Q SJ �.�V //w �/,J,• <br /> 7"AN K50> 35D,y a� e /o"S Qo✓ties <br /> jo <br /> �yl,�q�r1�v'fa <br />