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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES IV/mo REPORT BEEN FILED 7 ❑ YES ❑ NO I HEREBY CERTIFY THAT L HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE CASE n /� <br /> O N Y 'SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ra O L (20) Y68 306 <br /> w REPRESENTING ❑ OWNER;OPERATOR ❑ REGIONAL BOARD I COMPANY OR AGENCY NAME /, <br /> S �LOCAL AGENCY ❑ OTHER �y-�h Uk hr41y� <br /> ¢ ADDRESS <br /> 3vN g, G✓e%er f9ve S�v�l��orr C4 -T 2-0 <br /> STREET Gm STATE IIP <br /> J NAME CONTACT PERSON HONE <br /> �¢ U2 ! l4,nSe[7 Akk IGL' ❑ UNKNOWN <br /> H<y ADDR S <br /> YREST Cm STATE 71P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 ADDRESS 3& S;,4vz-k /vh STC <br /> O <br /> F STREET Cm COUNTY P <br /> -m CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w �$TC �nv��vo• Uiv ee.wl OZ l /1 �16Yd <br /> w REGIONAL BOARD PHONE <br /> m (7) NAME QUANTITY LOST(GALLONS) <br /> Q Je e- <br /> NKNOWN <br /> y0 <br /> mi <br /> w ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ IN ENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> w4. DI v �v ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAR (CHECK ALL THAT APPLY) <br /> m <br /> a (� ! S �' UNKNOWN [jREMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w u o o v r <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE M o r r ❑REPLACE TANK ❑ OTHER <br /> u <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> 10 ❑ TANK LEAK UNKNOWN EDOVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> w O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ma CHECKONEONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> iZ ❑ NOACTK)NTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> .y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDNTK)N 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 /> ISAAVARn7 <br /> a <br /> 00 OQ F-1CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(vE) ❑ OTHER(OT) <br /> /rtves4i /9r- so;/ cpm-Fu. ic.c Tal. cTy-r Sr Le occu.Vatd od. <br /> QGc, /, /p9y. So%/ su "7" /ts no.1o(<�ccf� �/t �vrclere�. S:�i 4-S" <br /> w out k, c /05&4q [iT OP <br /> HSC f61tNW <br />