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91-u.I 09 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE FOR LOCAL.AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED v ❑ YES NO I HEREBY CERHFYTHATI HAVE 9T81SUi THIS INFORMATION ACCORDING TO THE <br /> REPORT DA CASES DISTRI THE INSTRUCTON SHEET ON THE BACK PA OF THISF M <br /> z7 a <br /> u v SIGNED ` A, DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE S2L>TU <br /> RE <br /> AF— <br /> vEry A— dbs-3N <br /> REPRESENT O OWNEROPERATOR REGIONAL BOARD COMPANYC AGENC NAME <br /> S LOCAL AGENCY 0 OTHER %&"Z-A(E�/��0�t�fe- �(/✓/�/EJJ7T�L <br /> ADDRESS <br /> iij/0 WAM ZIPSTNEET Cm <br /> w NAME CONTACT PERSON <br /> i¢ PHONE <br /> UNKNOWN <br /> -N <br /> ZZ 0224 <br /> Hd ADDRESS <br /> cm C� - STAT , <br /> FACILITY NAME APPLICABLE) OP�EJRA�T�OR( PHONE <br /> $ tvAlD / FCiYV /Q �lj/j -b <br /> .j ADDRESS <br /> cm couNrr zIP <br /> —y CROSS STREET <br /> Z LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> F:wH saw T^'��"' via ��s� �,e/� �,e�vgiv <br /> w ,?d'Ar <br /> w REGIONAL BOARD PHONE <br /> s � ) <br /> m (0) NAME QUANTITY LOST(GALLONNSS) <br /> UNKNOWN <br /> ffiA17� OLL— <br /> H UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL 0 SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> 04 M D Y Y E] TANK TEST KREMOVAL O OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> NKNOWN REMOVE CONTENTS ;; LOSE TANK A REMOVE OREPAIR PIPING <br /> w <br /> Ml ol Y <br /> 8 HAS DISCHARGE BEEN STOPPED 4 O REPAIR TANK O CLOSE TANK E FILL IN PLACE O CHANGE PROCEDURE <br /> r YES ❑ NO IF YES.DATEM ol d <br /> 'I <br /> REPLACE TANK O OTHER <br /> Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j 0 TANK LEAK Pf UNKNOWN OVERFILL R REIFAILURE SPILL <br /> O O PIPING LEAK F-1OTHERE] CORROSION UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> O UNDETERMINED SOIL ONLY Ej GROUNDWATER Ej DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) - <br /> CHECKO NLY <br /> Z NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> jw F-� LEAK BEING CONFIRMED F-� PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O F7 REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F—] EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(In /Y <br /> I�ecx rwonAUR �J <br /> w4 CAP SITE(CD) EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) ` <br /> ¢a ❑ CONTAINMENT BARRIER(CB) O NO ACTION REQUIRED(NA) a TREATMENT AT HOOKUP(HU) Ej VENTSOIL(VS) <br /> 0 VACUUM EXTRACT(VE) Q OTHER(OT) <br /> )PEvfeW aA sord- f4 ,Aj TArtK AE/4a-,AL-- ?r.N C>! TE sdo)2[� <br /> calv�Ii9.4�N 7'ic�c(_ FviaTN&2 s-=re r�SE �F�VTty/GN far ,Gc4��eE1� <br /> F AVP <br /> .2 Fav �e6Pi4la°RaPR �.@ ?AeJ✓ i4GE NGG}! i4 n <br /> "sc m(m <br />