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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY � HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY. <br /> F-1YESI v U ^� REPORT BEEN FILED 7 <br /> ❑ YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> 1EPORT^DATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM <br /> V I� CASE a �p <br /> SIGN L CDATE <br /> NAME Of INDIVIDUAL FILING REPORT PHONE SIGNU� <br /> rAT <br /> pi c 2U`f ) 4tn� 7 'i�rLt� <br /> w REPRESE ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME S <br /> S LOCAL AGENCY ❑ OTHER CJ G � <br /> rr ADDRESS <br /> �o e <br /> CRY STATE •� <br /> ZIP <br /> J NAM�E�I1 y� CONTACT PERSON PHONE <br /> z Q FWN 1 YV S ❑ UNKNOWN I <br /> i s ADDDRR(ES <br /> 1.5� <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE YYY <br /> 4 <br /> ADDRES <br /> 1'; N f1ra+W 730 C,0"r, ,Q Stco-'1 � <br /> yCROSS STREET cRr <br /> EI Ywm.+- d- cft r)via <br /> Z LAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w nv i r DiWL AloA,,bt ( ti ,3Ap <br /> a t;;; R YA.t PHONE <br /> �)YY� T7(1 ( 1 11✓ �J�I IJ <br /> w (TI _ NAME QUANTITY LOST(GAL.LONS) <br /> UNKNOWN <br /> 25 m <br /> m ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> D 4 `JM 14 0,113 ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w <br /> ml dDI YJ y EZ UNKNOWN ❑REMOVE CONTENTSCLOSE TANKB REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK A FILL IN PLACE ❑CHANGE PROCEDURE <br /> o CeYES E::] NO IF VES,DATE DM -hD19 C y L . ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> �O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ,UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w Z ❑ NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> my ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J z I�ercR ra�a*wsl <br /> WO F-1CAPSITE(CD) F-1EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> wa ❑ CONTAINMENT 13ARRIER(CB) ❑ NOACTIONREOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> Pr❑ VACUUM EXTRACT[VE) ❑ OTHER(OT) <br /> r V � -JU wIF <br /> z <br /> w <br /> f <br /> HSC n(a q <br />