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• q <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> ❑ VES NO ❑ <br /> YES NO 1 HEREBY CERTIFYTHAT4,HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> *R�EPORTDATE DIISTR 18UUTION SHOWNN ONTHEIINSSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> R L,J1. CASE✓f 1 J Y SIGNED (�— DATE <br /> DIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ' ea S (�1ING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> AL AGENCY ❑ ,07HER - - E..F S �'/ I f�46 .1 I ASV Yl �-�+�'l JC�Q,G'UL Y7 <br /> ''��771/ ,1V / s�'. s <br /> STREET cm s ATe <br /> m NAME ' ^/ 4 CONTACTPERSON PHONEnp <br /> z V �Yr <br /> / ❑ UNKNOWN 15 `1J�✓" L).S (41,JC) I 1 <br /> a a <br /> ADDR_E,S/S� -,g� <br /> ✓t7f rJ Murkei , cc: '315 f Roo r CRY 64nFr-a,7ccsco 64 <br /> FACILITY NAME(IF APPLICABLE) STATE 71P <br /> OPERATOR PHONE <br /> r- edcrrLlZ u( IdI� Re ��►a N�c1(eys� AW-%-33,51 <br /> U ADDRESS <br /> s I N. S445oa vi ,., s bcK ToccuL n �15?A2 <br /> F, <br /> CROSS <br /> JSTREET p cm CAV Ilp <br /> LOCAL AGENCY <br /> ZAGENCY NAME CONTACTPERSON <br /> w S a� Maw Mei. S PHONE 04- <br /> Maj REGIONAL BOARD <br /> PHONE <br /> aoAME <4 Col QUANTITY LOST(GALLONS) X � <br /> O �� `I Y O C..�✓Y� �-J c� ERIUNKNOWN !/V <br /> V 00- (12 1NKNOWN <br /> �- DATE DISCOVERED HOW DISCOVERED <br /> w ❑ INVENTORY CONTROL O <br /> SUBSURFACE MONITORING <br /> u' OrCIONS <br /> SMI V M I-v -1 o r r ❑ E:]TANK TEST TANK REMOVAL LJ OTHER 4[.11.J_ <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M 01 Di Y y UNKNOWN REMOVE CONTENTS ❑CLOSE TANK S REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> p ❑ VES NO IFYES,DATE M MI o y Y ❑REPLACE TANK ❑OTHER <br /> U m SOURCE OF DISCHARGE CAUSES) <br /> D ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> w O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ETTUNKNOWN OTHER <br /> w CHECKONEONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w ❑ 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) <br /> IE Se EXCAVATE 8DISPOSE(ED) <br /> ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> az <br /> w O F-1CAP SITE(CD) ❑ EXCAVATES TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT A7 HOOKUP(HU) ❑ VENT SOIL(VS) <br /> F-1 VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> r-i"he� S I}c gsscss mervr will b e. J) <br /> ra,-fvre avid e.X4c/V' o(- ContapVXty tto/ Gt5 �iv�d <br /> > Y <br /> b --Jho aPpropv-Lal-e r"L)16& Q <br /> M9C OS IdB% <br />