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�. 9y- C -� <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? :I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES NO YES ❑ NO <br /> DISTRIBUTION SHOWN CN THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT GATE � CASE <br /> 7 <br /> G?' <br /> �y S DATE f <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> REPRESENTING COMPANY OR AGENCY NAMEv If <br /> F ❑ OWNEIVOPERATOR ❑ REGIONAL BOARD 7� �( <br /> S LOCALAGENCY ❑ OTHER SQ,iyT, � ( /,/ /7 Z <br /> ADDRESS 6-o-x 3 ?-e' <br /> STREET CITY STATE ZIP <br /> j NAME CONTACT PERSON PHONE <br /> m� ❑ UNKNOWN //1 / InL 6h/ �c�Yrir2/ (o�D )So1 X17 <br /> 05 ADDRESS <br /> % <br /> STREET CT' STALE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> �S co I�ho M. YU�G�u�a `' (ao ,TJA 7e' <br /> ADDRESS b L �' �• 5a O <br /> ZIP <br /> y CROSS STREET <br /> rn s <br /> p LOCALAGENCY i AGENCY NAME CONTACTPERSON PHONE <br /> _� San �orc P/fS-E H D Ley,frw �r; s �t4 1Lf�e-3 <br /> w a REGIONAL BOARD <br /> / PHONE <br /> y A E / � QUANTITY LOST(GALLONS) <br /> �J X Y (p�Jso UNKNOWN <br /> m ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M l 6.1qr r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> aUNKNOWN REMOVE CONTENTS CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> w M DI YJ r 1.1 T� <br /> HAS DIS YES ❑�NOSTF VES, DATE 'M / / o J /r / Y ❑REPLACE TANK REPAIR TANK CL❑OTHPROCEDURETANK d FILL IN PUKE CHANGE PROCEDURE <br /> 0 <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> mO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> �J3 ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY _f <br /> w0 NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION �1 <br /> �y LEAK BEING CONFIRMED F-1PRELIMINARYSITE 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 d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATON(IT) <br /> <Z IffEerx Rl110tTAl8I <br /> w p ❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ~ ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL DIS) <br /> 2 4 Y <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) evee�=;�� <br /> lAe <br /> s 0r� <br /> ��I�R <br />