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C..� - wC�, <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES nrJ/ NO REP ORT BEEN FILED? ❑YES ❑ N 1 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• <br /> Ml D ?/v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> t <br /> W,0, /t 0 <br /> tD <br /> REPRE NOWNERNPERATOR TING REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S <br /> ❑ ❑ <br /> cLOCAL AGENCY EDOTHER <br /> ADDRESS '7 /1 �A/,(Jl.,(i(iI7 Q,v,f ���•i(yi�� / 4 <br /> TREEETU <br /> c7V W (lye `Z,UW(/ (/�{WATE <br /> SCRYY <br /> w NAME CONTACTPERSON PHONE <br /> z¢ 2 �y��j�y❑] UNNKNN�OW/�N�"y��,��r � l�w�1 ,4 W oRS /�A (qt�) Z�y� <br /> y< ADDRESS <br /> ",0,32 S. r YWIOKJ A l `ice W w"�G�`�� C � <br /> ya <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z I 2 <br /> O ��.5}� <br /> ADDRESS <br /> <7CJ'Z S. r/ r . �Y\ / /)/( /)f'�nb <br /> STREET Yv CRY CDUNTY(� OCW& <br /> yCROSS STREET <br /> p LOCAL AGENCYAGENCY NAME CONTACT PERSON PHONE <br /> zy � <br /> z <br /> w <br /> ww REGIONAL BOARD PHONE <br /> y (T) NAME OUANTITY LOST(GALLONS) I <br /> w p <br /> j UNKNOWN <br /> �z m <br /> �? <br /> y ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ ENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ❑ <br /> M o r TANKTEST JZ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCH GE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS C <br /> RAI <br /> TANK&REMOVE ❑REPAIR PIPING <br /> Iy D Y Y <br /> p HAS DIS KARGE BEEN STOPPED? ^ ❑REPAIR TANK ❑CLOSE TANI FILL IN PUKE ❑CHANGE PROCEDURE <br /> p YES ❑ NO IFYES,DATE lM V I l /�Y !/ E]REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE M vCAUSE(S) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ PTUREIFAILURE ❑ SPILL <br /> ,a <br /> yp ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHEC NEONLY <br /> UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> a <br /> �� ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Z IRE 6ILItRADETAIR <br /> w 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REWIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACTIVE) ❑ OTHEP(OT) <br /> y <br /> z <br /> 2 <br /> w <br /> E <br /> oZ <br /> U <br /> NSC os 1&'541 <br />