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OI - c �� l <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 NO REPORT BEEN FILED? <br /> 0 ❑ YES E�jry0 1HEREBY CERTIFYTHAU HAVE DISTRIBUTED THIS INFORMATION ACCORDINGTOTHE <br /> REPORT DATEcABE s DISTR IBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> n <br /> Z I , SIGND) DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m Ali son D .Mood c2a��F1�-q�4 G <br /> REPRESENTING O OWNEWOPERATOR a REGIONAL BOARD COMPANY OR AGENCY NAME <br /> [� <br /> R LOCAL AGENCY O OTHER !1H1J(` �,(� <br /> ir ADDRESS P :& C5fn <br /> �.webP.rAY„e _,'fhlyd �loa� StDc4ftn CA q5Z 71, Z- <br /> GRY BTATE <br /> w NAME <br /> C r�� � � /� � /� � �7 �ON PH�O�NEy �3C <br /> i� JOU � L.-L.-l_. UNKNOWN (j TCONTACT PERSLIJL-IC �C-(.t I(N�1) LTJ^ <br /> H ADDRESS Vl <br /> l05 W . 'rzv1-f LI 9eraservZP TJq U1 6A 9-g537 <br /> cm sTATE ,n <br /> FACILITY NAME(IF APPLICABLE) OPERATORPHONE <br /> O t ) <br /> a ADDRESS <br /> � (012 W. CI�✓2�-t�► SfiY�I- Trey 5ari1S�4��tin �?�37� <br /> CROSS STREET ap <br /> Tea" <br /> O LOCAL AGENCY AGENCY NAME CONTACTPERSON PHON <br /> z <br /> m <br /> w onto (2oq)4l6-3449 <br /> ww REGIONALBOAR PHONE <br /> CY ovtCLQ ISG+" Cg ( ) <br /> w (0) NAME QUANTITY LOST(GALLONS) <br /> �DNKNOWN <br /> 25 (8 <br /> H- xE ' <br /> ❑UNKNOWN <br /> i <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> V IPM I ( o Or I r ❑ TANK TEST ✓TANK REMOVAL ❑ OTHER I� <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M p Y ED'IUTS CLOSE <br /> NKNOWN ❑REMOVE CONTENQ TANK&REMOVE E]REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o Q VES ❑ NO IF YES.DATE ()M 6 I o S J v Y I r ❑REPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANKLEAK UNKNOWN ❑ OVERFILL O RUPTUREIFAILURE O SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION Q UNKNOWN O OTHER <br /> w�w` CHECKONEONLY <br /> F UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> dNO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMDTED O POLLUTIONCHARACTERI7ATION <br /> wZ <br /> �y ❑ 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) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> I�enuswonwW <br /> ❑ CAPSrrE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> ? ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) <br /> ❑ TREAyTMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) 5a, OTHER(OT) � <br /> hDX Sly, iY, r6ju ; A' ;0 G.Q�/l2� <br /> H9C OS(� <br />