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0\1-v,`) �, <br />UNDERGR UND STORAGE TANK UNAUTHOR ZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV S <br />REPORT BEEN FILED? <br />FOR LOCAL AGENCY. USE ONLY <br />❑ VES NO ❑ VES NO <br />( CERTIFYTI HAVE DISTRIBUTED HIS INFORMATION ACCORDINGTOTHE <br />AT <br />ISTRI ION SHOWN ON THE INS UGT1 "4� 0 E Af�i< PAGE OF THIS <br />fv! LQ7 <br />REPOR ATE <br />t Iy <br />CASE <br />S DE <br />NAF)$pEII�DIVgUAL FILINfiREPORTD � <br />IIV//❑ <br />pH ��/W IGN RE <br />m <br />w <br />REPRESE NG^/ <br />OWNEROPERATOR ❑ REGIONAL BOARD <br />� <br />CC"79R AGENCY - <br />S <br />S <br />LOCAL AGENCY ❑ OTHER <br />`/f <br />Jj�j <br />ACTS /\i SardE�da 5 foc n 0AAM 8520 <br />ZIP <br />j <br />i ¢ <br />NAME /� y� ,^I D' / <br />61 K horn CVU/ {�W ❑UNKNOWN <br />TA/C�T RSON L <br />'C.' <br />PHONE <br />aO y <br />a <br />ADDRESS yI ry <br />'DS� �1 Khor 3TRF V • �� Il/C Kms' C STATE �,L_ _ IP I <br />FACILITY NAME (IF APPI-IrABLEL, <br />Khorn ubilrt4rqwb <br />QPERATPR PHONE <br />e-55 1) qn-g85 <br />a <br />(00 <br />a <br />w <br />ADDRESS �7 <br />`D� 4FlKho;,2, al • 95 9 <br />y <br />CRSTREET , <br />W <br />Je <br />pL <br />Z y <br />F <br />GE CV AGENCY NAME <br />�•' <br />CONTACT PERSON <br />PHONE <br />W <br />w <br />RERBC RD^ <br />PHONE <br />y <br />Q <br />D) NAME OUANTITY LOST (GALL ) <br />y �T <br />J0 /� UNKNOWN <br />r <br />m <br />Q UNKNOWN <br />i <br />DATE DI VEREDI7.9 <br />/_ <br />Du� ©d / <br />HOW DISCOVERED ❑ VENTORY CONTROL ❑ UBSURFACE MONITORING O NUISANCE CONDITIONS <br />MI v D y y <br />❑ TANK TES TANK REMOVAL OTHER ���E�Ii��S SCjI �5�� <br />m <br />a <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARC,F (CHECK ALL THAT APPLY) <br />¢ <br />w <br />UNKNOWN <br />u D Y yl <br />❑flEMOVECONTENTS LOSE TANK A REMOVE ❑REPAIR PIPING <br />L}�QC/ <br />p <br />HAS DIS RGE BEEN STOPPED T <br />❑ REPAIR TANK ❑ CLOSE TANK E FILL IN PLACE ❑ CHANGE PROCEDURE <br />o <br />YES ❑ NO IF YES, DATE a I <br />Q REPLACE TANK ❑ OTHER <br />u 1 y y <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />F-1 TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE E]SPILL <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION1NKNOWN O OTHER <br />ww <br />CHECKONEONLY <br />❑ UNDETERMINED We SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />2 Z <br />F-1NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />�y <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE& DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />Pff —.7w <br />4 <br />F-1 CAP SITE (CD) ❑ EXCAVATE& TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />w< <br />❑ CONTAINMENT BARRIER (CB) [::] NO ACTION REQUIRED MAI ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />VACUUM EXTRACT (VE) F7 OTHER (OT) <br />Vr.Mer 51 t Ire. rntm/te <br />P X�P/1ti� (j f COYI iZ�/1 vl l n al Lor► ac-.) re, �� <br />0 a <br />Hscw(� <br />i; <br />