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0 <br />0 9y_ v 5 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED 7 <br />FOR LOCAL AGENCY USE ONLY <br />❑ YES NO YES ❑ NO <br />IHEREBV CERi1FYTHAT i;HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TO THE <br />DSIFiI TIgJS N ON THE IbSTRUCTON SHEET ON THE BACK PAGE OF THIS FORM <br />iI < �.) � '+T�� <br />�Z '!1✓ L� / f <br />RE/PORT GATE l///]' <br />OM <br />CASEt <br />S ED DATE <br />N I r <br />NAME OF INDIVIDUAL FILING REPORT <br />B r i S <br />PHONE SIGNATURE <br />6?8R)y&g ,3 y6 <br />m <br />,Leif <br />w <br />REPRESENTING F-1 OWNER/OPERATOfl ❑ REGIONAL BOARD <br />COMPANYO ENCY NAME <br />JpHS ��, <br />S <br />LOCAL AGENCY ❑ OTHER <br />�`((h���(.,�1��'4� ` <br />D vb, Ag-erx �7 �6 S -to c w4yl0✓ 7,Q <br />✓l - Q <br />STREET CT/ STATE 2 <br />p <br />j <br />NAME <br />CONTACT PERSON <br />PHONE <br />- ❑ UNKNOWN <br />S <br />,� rr <br />OpV) 7AJa' <br />671 <br />STPEET Cfry STATE 21P <br />FACILITY NAME APABLE) <br />7rur✓�6&sin <br />OPERATOR PHONE <br />� <br />Sco tf GoWa-rccgilo)�7a <br />0 <br />° <br />ADDRESS /` �., , <br />�5 0 (-� Rd, QS-fo1.��&m`%n:-,1- <br />� U <br />p <br />yCROSS <br />STT <br />� Q <br />O <br />F" <br />LOCALAGENCV V AGENCYNAME <br />s- l� <br />CONTACTPERSON <br />PHONE <br />&F <br />w Z <br />REG NAL BOARD (^ <br />PHONE <br />y <br />(1) NAME QUANTITY LOST(GALLONS) <br />wp <br />Q J <br />n UNKNOWN <br />m Z <br />(2) <br />N <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />�D �Y �Y <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />M `' M ' D <br />❑ TANK TEST ❑ TANK REMOVAL OTHER <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARG (CHECK ALL T APPLY) <br />❑ UNKNOWN <br />M o o r r <br />❑ REMOVE CONTENTS ❑ CLOSE TANK& REMOVE ❑REPAIR PIPING <br />w <br />REPAIR TANK ❑CLOSETANK & FILL IN CHANGE PROCEDURE <br />DISCHARGE ND <br />oHAS <br />I <br />NOIFYES. DATE /MW^Ml 5.'7r Br <br />❑ REPLACE TANK OTRlet Q <br />D <br />OURCE OF DISCHARGE <br />CAUSE(S) <br />w <br />a❑ <br />TANK LEAK ❑ UNKNOWN <br />❑ OVERFILL RUPTUREIFAILURE E::]SPILL <br />hO <br />LEAK <br />PIPING F-1OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER <br />yw6 <br />CHECKONEONLY <br />O <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN A <br />-FECTED) <br />CHECKONEONLY <br />w <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />�y <br />BEINGLEAK CONFIRMEDO IS POST CLEANUPMONITORING IN PROGRE <br />O <br />F-1REMEDIATIONLAN CASECLOSED(CLEANUP COMPLETED OR UNNECESSARE] CLEA UPNDEW P <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRAI <br />ISEt erx raAOETusI <br />ATION (IT) <br />00 <br />❑ CAP SITE (CD) ❑ EXCAVATE& TREAT(ET) ❑ PUMP& TREAT GROUNDWATER (GT)❑ REPLACE SUPPLY IRS) <br />❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUUIcIR,,E,DD INA) ❑ TREATMENT AT HOOKUP(HUI ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) OTHER(OT) P3'1 / SeSS <br />112 <br />r-uk� 2SseGg' rnav� vV`L <br />PL --O-- <br />8 <br />U 70I� <br />