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O <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTA NATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> YES NO <br /> REPORT BEEN FILED 7 ❑ VES I HEREBY CERTIFY THAT I.HAVE DISTRIBUTED THIS INFORMATION ACCCROING TO THE NO - <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASES <br /> wl wl 4 ol A Y -SIGNED - DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME ( / _ <br /> g LOCAL AGENCY ❑ OTHER A S,'►.► �J Q 11.1�.) 1(�vbtj f /'e E 4 b <br /> w ADDRESS � . VV'e 6..---r <br /> (FAQ, 3rcl x'001 (J�j%ol6fL* Cry`] <br /> 30 S REST ( C" STATE zip <br /> NAME ,n CONTACTPERSON qq PHONE <br /> iQ .00 �tJ � ❑ UNKNOWN (2�)GYq-3?35 <br /> y u ADDRESS <br /> Q, C. Go< (003 STREET GTY Ar-des%,A SCR go�v2 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> D If 5L1 _ (J 0, 0A6bx.. in �u6 tna J; ( ) <br /> a ADDRESS� r M+I . ' Lob; <br /> 5-01 W• 9TREEf Qi �} lt�J l crtr 1►V D+ CA couNry � R <br /> CROSSSTREET 1 <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> IIJ so &4r\ U^( 61k 1) r a�e+rlr L*A 0tr-i D (2.0,11 L!(o -3Yti9 <br /> w ZwU REGIONAL BOARD PHONE <br /> ` it4( I1 Ua QQ, 64/'�v�j Hl6125�-31►5 <br /> m (1) NAME OUANTITY LOST(GALLONS) <br /> Teri - gV l� UNKNOWN <br /> i (21 <br /> N <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITKINS <br /> M o Dr Zr ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wM p Y UNKNOWN ❑REMOVE CONTENTS OSE TANK 6 REMOVE ❑REPAIR PIPING <br /> 8 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE E:]CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATEM C Y v ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> �a ❑ TANK LEAK UNKNOWN F-1OVERFILL E] RUPTURE/FAILURE ❑ SPILL <br /> y0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION 15� UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ® UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> ¢Z ..F-1 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy LEAK BEING CONFIRMED ❑ PRELIMINARY SITE 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 b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED SIO DEGRADATION(In <br /> �s.uro�oFrww <br /> 0 4 ❑ CAP SITE(CD) ❑ EXCAVATE a TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> 2aF-] CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED INA) ❑ TREATMENT AT HOOKUP(HUI E:] VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(0-0 <br /> Car4#L h .Y�AA- Ton be. tnocs4l L+"Z_ � and rtw��aca <br /> a S r�._cess a r b re-s P 8 S L b t e POLY- { . <br /> UHSC�(�O <br />