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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 /> REPORT BEEN FILED? <br /> VES T�NO AYES E NO 1HEREBY CERTIFYTHAT4 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE <br /> DISTRIBUTION SHOWN ON THE INSTRU PON SHEET ON THE BACK PAGE OF THIS FORM <br /> CASEL � /��� <br /> 7 D y 9 Y S6, <br /> IS DATE <br /> NAME�OF ISN IVIDUAL FILING flEPORT PHONE SIGNATURE <br /> /�EN.vErf .,.•• (spa)Pyz-a75Z <br /> p COMPANYOR AGENCY NAME <br /> �y REPRESENTING pWpEpppEpp7pp Q REGK)NALBOARD <br /> S E] LOCAL AGENCY OTHER (,/YB✓.PON (/ S/l.� �iVC. <br /> ADDRESS <br /> Zy/O(��lFl.„A�/T'.IMON srB r �/J� AAMON cmAL/FOWAII.4 WAre 9y,S83zIP <br /> J <br /> NAME <br /> /A•/�/ / A CONTACT PERSON PHONE <br /> i (/// E✓ROH U. , �Nc. Q UNKNOWN En/.✓ET/1 ,¢�v (s/�)8f/Z-87SZ <br /> a d ADDRESS <br /> y <br /> Zf/llCi9M/•Va/rAi`fON STREU CITY AG/FORiv/A a AW 9y.�a3 Ip <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o G/�eva�.✓ �vrio.� 9- D9S9 ✓/yEs / /�sEC�✓Y I (y-9)23S 7yoo <br /> ADDRESS T C // <br /> /O31NESr��iY7TA? srB�r ;; i4,'Y cm SN ✓DAR ax" couxTY 9.5.37 zIp <br /> m CROSSSTREET <br /> p L�OCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> P: :i/N 1010MIAI LOc oc ws-3f/xe <br /> w REGIONAL BOARD PHONE <br /> � <br /> .�rW1 Y44ZZ �6/aT,-JiyCP/1MENT0 (jDPvav/ 0665 (9/6 )3 /-S6Do <br /> y (1) / , NAME QUANTITY LOST(GALLONS) <br /> Z> Q UNKNOWN <br /> �O W <br /> y Z <br /> Q UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED O NVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS ' <br /> zM �?C 9 / Y TANK TEST TANK REMOVAL OTHER �j�Q / <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN EffflEMOVE CONTENTS D CLOSE TANK&REMOVE REPAIR PIPING <br /> w M D Y Y <br /> HAS DISCHARGE BEEN STOPPED? Q REPAIR TANK Q CLOSE TANK A FILL IN PLACE 0 CHANGE PROCEDURE <br /> o YES O NO IFYES,DATE �REPLACETANK OOTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j Q TANK LEAK UNKNOWN OVERFILL RUPTURE/FAILURE O SPILL <br /> a <br /> w O F-1PIPING LEAK Q OTHER CORROSION � UNKNOWN O OTHER <br /> w a CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY GROUNDWATER O DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w O NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED a POLLUTION CHARACTERIZATION <br /> w O LEAK BEING CONFIRMED F--j PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) EVr CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) & EXCAVATE&DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) E:j ENHANCED BIODEGRADATION(IT) <br /> I�A�urwoeTuel <br /> og CAP SITE(CD) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)Q REPLACE SUPPLY IRS) <br /> wa Q CONTAINMENT BARRIER(CB) O NO ACTION REQUIRED INA) TREATMENT AT HOOKUP(HU) Ej VENTSOIL(VS) <br /> O VACUUM EXTRACT(VE) Ej OTHER(OT) <br /> y N vim°vd--( 4v,P—9 a , �"t�� < a ss�sss>, w ` <br /> L'B/v�/d'/v) � i✓ �7oiJ /#-5 /2l�u iKCe! �V �kG GL/�f'��•uQ.r� Q�i!^-G� i <br /> \ N9C f6IMiq <br />