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arrow — q) - cA. 4a� <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY - <br />REPORTBEENFILED7 <br />❑ VES NO ❑ YES E:] NO <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTIONS OWc_ �1 NIXJ THE INSTAUCTgN SHEET ON THE BACK PAGE FTHIS FORM <br />Cf ' -'F--' 2- <br />ic, <br />REPORTDATE <br />CASES <br />O u M <br />SIGNED DATE <br />ATE <br />NAME OF INDIVIDUAL FI ING REPORT <br />PHONE <br />SIGNATURE <br />NAM <br />REPRESENTIN REGIONAL BOARD COMPANY OR AGENCY NAME <br />OWNER/OPERATOR CO'aate�( AGENCY <br />lOv�' , / �� ^ " �Y <br />SLOCAL <br />AGENCY ❑ OTHER~ J✓>•�'K (/y`F f <br />ADDRESS /— _ <br />Cm STATE ZIP <br />w <br />//N��A�MME <br />Vx�fqG!L= Q^V FAM -rr/ <br />CONTACTP/ERSRSyO�N <br />PHONE <br />+, <br />( )�V�-I>�� <br />❑ UNKNOWN <br />oaADDRESS <br />w <br />srREEr cm sTATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />O <br />(PHONE <br />) <br />`a <br />ADDRESS,/JJ `._e, / .i.� -JvAeaw <br />` / /`L_R'E/ET'/ I'ir /IDF^.V,�f �A4 '^`E <br />/ <br />6 �/• <br />!�•'/ Cm CWNTY ZIP <br />y <br />CROSS STREET <br />aa <br />Ae-,AmYo 4Q <br />O <br />LOCALAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />w <br />t(� �N tv. /SNS- Ef11� <br />�i2lL �Rcv,6A14- <br />w <br />REGIONAL BOARD <br />PHONE <br />fa <br />G✓IQWQG <br />( ) <br />0 <br />NAME QUANTITY LOST (GALLONS) <br />- <br />❑ UNKNOWN <br />m <br />(2) <br />i <br />w <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INV NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />��77 p� <br />CMI D ( <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />u !moo lY y <br />m <br />a_ <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHECK ALL THAT APPLY) <br />u o y y UNKNOWN <br />❑REMOVE CONTENTS CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br />w <br />E:] REPAIR TANK ❑CLOSE TANK d FILL IN PUCE ❑CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />ES <br />❑ VES ❑ NO IF YES. DATE <br />j.1 dy <br />OREPLACE TANK OOTHER <br />ml y <br />SOURCE DISCHARGE <br />CAUSES) <br />¢j <br />TANK LEAK ❑ UNKNOWN <br />❑ OVERFILL ❑ R REIFAILURE ❑ SPILL <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />ww <br />CHECK ONE ONLY <br />Q <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHE EONLY <br />rw NO ACTION TAKEN -. ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />w <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />I>aff e.cR rw oerAUl <br />ai <br />❑ CAP SITE (CD) ❑ EXCAVATEb TREAT (ET) E]PUMP& TREAT GROUNDWATER (GT)❑ REPLACE SUPPLY IRS) <br />? a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) E::] VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) O OTHER (OT) <br />sora YQJC-, Tg F.ao.y <br />w <br />SZr� �4s��Fy�.�rEnlT wt�GBE RF4D ?3 r�Erc� �7T/� n/�¢?t�e� <br />At�(v �XTENTa�F �or�lT�«n/i2rio�/. /a-5 RE4��i.�'Ep (3Y T'rrE,e�G�x.�trcrQ�- <br />/iC�n/�Y <br />