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99 . uy8 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> E❑ VES NO <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERNO TED VICES FOR LOCAL AGENCY USE ONLY <br /> LJ�Q/ REPORT BEEN FILED? ,[Y(YES I HEREBY CERTIFY THAT I HAVE DISTRIBUTHIS INFORMATION ACCORDING TO THE <br /> '. <br /> DISTRIBUTION SHOWN ON THE INSTRUCTgN SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATECASE at <br /> 0.17.1 ISIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> VI DAL 'E FDR r2-A (zoo1) 1469-Os-_;3 Zi.l� <br /> w RENTING F-1OWNERIOPERATOR ❑ REGIONALBOARD COMPANY 01 AGENCY NAME <br /> S <br /> PRES7OCALAGENCY ❑ OTHER (��S �I I ✓ <br /> ADDRESS <br /> 4 REU CT' STATE ZIP <br /> w a s NAME <br /> CONTACTPERSON ' PHONE <br /> rNF,9 ✓L L' c TC. E] UNKNOWN WADS9) a 70i¢ <br /> O <br /> ADDRESS <br /> J�oa w TvrnfER hid C� Ds c/+ Gszz/2 <br /> STREET CDY STATE ztp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o RAL. MlU-S //JG LO" PTT 676N&2PL AAZLLS IAl4 I (Zd�9) 3,3q- A)qD <br /> ADDRESS I rw W �V�./"p Lv D..T �!n n/ -ToA47 glToD Cm <br /> c NW ZIP <br /> C, CROSS STREET <br /> Mzl-us <br /> a LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Wo Coul'I'T1 P►+S &t+b Nil DAL pEDR AzA (coq)4&8--03n <br /> w 1 REGIONAL BOARD PHONE <br /> as ( ) <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> D �, �sEL FuCL- <br /> UNKNOWN <br /> U <br /> w <br /> a <br /> m (2) <br /> z_ <br /> H ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ NVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> rI q, ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> > YrUNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING fl <br /> w u o D r r `V <br /> HAS D CHARGE BEEN STOPPED 7 ❑REPAIR TANK &CLOSE TANK A FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE DM uI Do ` v r ❑REPLACE TANK ❑OTHER <br /> iB SOURCOF DISCHARGE CA (S) <br /> M TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> m0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� F-1NOACTIONTAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED E::] POLLUTION CHARACTERIZATION <br /> r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> L y <br /> ®REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> I5H avx RA MiuBl <br /> a z <br /> 00 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) <br /> wF <br /> a ❑ CONTAINMENT BARRIER(CB) OACTgN REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) �i l <br /> �" VJC <br /> •'�t;W 444C4*x: v /ufC cAaf -G° G(A&4.r ,✓h.LG' ex, wa*4, 444.4 c�=•(f'�gG�LT� y� <br /> IF <br /> KSC 0.51beq <br />