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J U 32- <br /> 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? YES No ]HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ VES NO ❑ DISTRIBUTION SHOWN ON THE INSTRUCTION(SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTGDATE CASE0 <br /> QN Vq ( 3 Ty S NED LATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE NATURE <br /> Jere h(o k4 (t04 146&0--3S L <br /> w REPRESENT OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> ¢ ® LOCALAGENCY ❑ OTHER <br /> S /�J <br /> ¢ ADDRESS CAQSZVL <br /> 3" � W cJ0'= - Ave— Stxkto� <br /> STATE z1P <br /> j NAME 1� CONTACT PERSON PHONE <br /> is �'w'FGr hSG �hUCSrw(G+a^� ❑ UNKNOWN Rrs. Mar �-OJ'v`� <br /> y< ADDRESS L--- ('� -T <br /> ha Al. m� br vc- —U SCAN T� <br /> ¢ 1 <br /> 39 l ,V STIR cm STATE TIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> 2c5- <br /> jE;n- —y`Qe-"lac- cm Zan <br /> Voau �L <br /> ZIPT W <br /> w <br /> y CROSS STREET <br /> Larcl N <br /> p LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> I w Lo kl]-- (Zb4)4l0 8-033 <br /> w W REGK)NAL BOA PHONE <br /> w (7) NAME QUANTITY LOST(GALLONS) <br /> W <br /> O S �iC UNKNOWN <br /> a3 <br /> F- <br /> mi <br /> m ❑ UNKNOWN <br /> i DATE DISCOVERED (1 HOWDISCOVERED ❑ INVENTORYCONTROL ❑ SUSSURFACEMONITORING ❑ NUISANCE CONDITIONS <br /> 2 Chu ( �o ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> aUNKNOWN <br /> E)REMOVE CONTENTS CLOSE TANKb REMOVE ❑REPAIR PIPING <br /> w M <br /> D1 Yl r <br /> HAS DISCHARGE BEEN STOPPED? REPAIR <br /> ❑REPAIR TANK ❑CLOSE TANK b FILL IN PUCE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE OMI `�R j I <br /> .1 <br /> '� l r r ❑REPLACE TANK ❑OTHER <br /> iD SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAKUNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> �+O ❑ PIPING LEAK n OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMRTED ❑ POLLUTION CHAfiACTERIZATION <br /> jN IXI LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O +❑ REMEDIATION PUN ❑ 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 /> lag B/LI((OICETAl3) <br /> op ❑ CAPSITE(CO) ❑ EXCAVATE b TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> uI~ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢a <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 'FLar*k-.v- jIA-- bc. rcc u(ec4 +r-D dc+crw t,,tr -+4^c <br /> 8 °.('P�rLo� ffLcLn <br /> c <br /> HSC 6 1�% <br />