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N9c m (89R <br />iS <br />55 <br />ID <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE <br />REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ;'FOR LOCAL -AGENCY'USE ONLY <br />REPORT BEEN FILEDi <br />YES NO <br />y ❑ NO ;1HEREBYCEHTIFYTHATl HAVE DISTRIBUTED THIS INFORMATIONACCORDING 70 THE <br />REPORT DATE DISTRIBUTION SHOWN CN THE INSTRUCTION SHEEP ON THE BACK PAGE OF THIS FORM. <br />CASE s <br />LO �MI Y q <br />SIGNED DATE <br />NAME OF INDIVOUAL FILING REPORT PHONE SIGNgTURE <br />, <br />wo1) laS,3,f(o <br />lOy <br />REPRESENTING ❑ OWNERlOPERATOq ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br />S <br />LOCAL AGENCY ❑ OTHER Lt yL JB a P/y s - <br />ADDRESS <br />30,41- E 0,&. , d+ u -e, 3!1-4 <br />4T11EET <br />Z <br />Cnv STATEnP <br />NAMa�J A^ CONTACTPERSON PHONE <br />Z ¢ <br />V'( O UNKNOWN / OI <br />1/ <br />ADDRESS'7 <br />ya <br />/ west Pahl R(}Z• <br />FACILITY NAME (IF APPLICABLE) Gry =Are <br />OPERATOR PHONE <br />p <br />a <br />ADDRESS <br />028-5 © .�o o Yn, s rot. S -�o G K�r�. do )r/5 <br />y <br />CROSS STREET CITY COVNrr P <br />.H vu9 -Fren a <br />z <br />LOCAL AGENCY AGENCY NAME CONTACT PERSON <br />S� H lea HONE <br />(2 PHS- FN�� l/1/1 P�9)'�btt-.35 <br />w w <br />a a <br />f <br />REGIONAL BOARD <br />C 3 PHONE <br />( ) <br />y <br />I,> <br />^ n /I"ME OUANTfTY LOST (GALLONS) <br />o <br />UNKNOWN <br />m> <br />m <br />N <br />UNKNOWN <br />i <br />DATE DISCOVERED 9 9 HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIO S <br />�o <br />I!! <br />/ / y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br />m <br />a <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THA PLY) LLAT, <br />w <br />u o UNKNOWN <br />�EMOVE CONTENTS LOSE TANK REMOVE ❑ REPAIR PIPING <br />NAS DISCHARGE BEEN STOPPED? <br />YES Q� <br />NO © 9� a 9 9 <br />—p <br />REPAIR TANK <br />❑ ❑ CLOSE TANK d Fal IN PLACE ❑ CHANGE PROCEDURE <br />❑ IF VES, GATE <br />V r <br />REPLACE TANK ❑OTHER <br />SOURCE OF DISCHARGE <br />CgUSE(S) <br />a j <br />a <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURWAILURE ❑ SPILL <br />w O <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />Ha <br />CHECK ONE ONLY <br />O <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEENAFFECTED) <br />CH�EECyKKONEONLY <br />wNO <br />ACTION TARN ❑ PRELIM iNARY SITE ASSESSM ENT SUBMffTED <br />j m <br />O <br />LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONRORIINNG W PROGRESS <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNOERWAY <br />CHECK APPROPRIATE ACTION(S) EXOAypTEa DISPOSE E <br />P@cW IwoFTYA ❑ (D) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCEDBIODEGRADATION(M <br />❑ CAP SITE <br />Do <br />(CO) ❑ EXCAVATE& TREAT(ET)r PUMP&TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />a <br />❑ CONTAINMENT BARRIER (CS) NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (H-ll)�( ❑ VENT SOIL (VS) <br />yyy❑,,{{{ <br />❑ VACUUM EXTRACT (VE) OTHER (OT),5; <br />� <br />A" ✓V'LC_. �'i-t�� <br />o <br />��%��(i�JZl"wiv�i lA�/ `W 1 <br />_!' ��/ <br />N9c m (89R <br />iS <br />55 <br />ID <br />