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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 /> ❑YES NO REPORT BEEN FILED 7 ❑YES ❑ NO HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORT DATE CASES THE EAL O5, YCODE -� <br /> _rf f Ll <br /> N 9 /�M � ! Y`� Y 'DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Lej ,- 'a P25C-A, ( <br /> REPRESE ING F-1OWNEWDPERATOR ❑ 3EGK)NALBOARD COMPANY OR AGENCY NAME <br /> LOCALAGENCY ❑ OTHER <br /> ¢ AODRE4iS n, aao <br /> 19�, fox // ��t6c�,�o/w�,��j(/�� Ct4 95a4l <br /> ON HONE <br /> vi�� NAME C+.(-e �rd f R !/• ❑ UNKNOWN !'J l a r K <br /> ADDRESS q <br /> . Iti..O(.c�T cm TE L a <br /> Pb <br /> $ ap <br /> FACILITY NAM APPLK:A%E) D rd ^' � OPEMTOR PHONE` <br /> ADDRESSA � e4% !amp <br /> �+ CITY ZIP <br /> CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> REGIONAL BOARD u PHONE <br /> rn (1) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> t- <br /> (a <br /> ❑ UNKNOWN <br /> DATEi DI oVERED� /i D ❑ QST ❑ TMl(REMOV �L n .gURRFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 7 LZJ/ <br /> M M 116.1 <br /> Y Y <br /> DATE DISCHARGE BEGAN METH-IODDUU�E0 TO STOP DISCHARGE(CHECK ALL THA Y) <br /> 1 u M D D Y KNOWN UQ ^ZWOVE CONTENTS ❑ REPLACE TANK "CL TANK <br /> HAS DISCH BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPFWG El CHANGE PROCEDURE <br /> YES ❑ NO FYES.DATE © 3u 3D UD DY ❑ OTHER <br /> GSOURCE OF DISCHARGE CAUSES) <br /> w <br /> w ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> 111 ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON Y <br /> �O1 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �i <br /> $w ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> SS ❑ REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FRI ❑ ENHANCED SO DEGRADATION(M <br /> 2 I�ecRrwoerval <br /> EXCAVATE (ET) ❑ PUMP TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> F-1 CAPSITE(CD) ❑ <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED INA) ❑ TREATMENTAT HOOKUP(HUI ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT NE) [OTHER(OT) Ig czC%P SS max - <br /> J IBc 0.s p veal <br />