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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL' AGENCY USE ONLY REPORT BEEN FILED 7 ❑ YES NO [7] YES O I HEREBY CEFMFYTHATI /q�A�V�E� DISTRIBUTEDTHIS INFORMATION ACCORDING TO THE DISTRIB ! f PTnE-wSTRUCTION SHEET ON THE BACK PAGEOF THIS FORM -t REPORT TE CASE i / z"`+ SIGNED DATE M L NAME OF INDIVIDUAL FILING REPORT� GG NE ( lq)��r,�o� m w O�^OWNER/OPERATOR ❑ REGIONALBOARD REPRESENTING COMPANY OR AGENCY NAME g OCAL AGENCY ❑ OTHER sT-�+� �Ty��J �/ % �� ADDR S 15 - / S/j/Y S�Q i� ^�/ J / C/e/ G c;!/V / jiJ /`/_ /v STREET Cm STATE 21P w 0 i ¢ NAME --,' ❑ UNKNOWN ODNTAC PERSON 737 OLA PHONE (' 7�7 G�76 On n ADDRESS e n /E /G� f`'� /� CYKGJ /�J /0� 'V ¢ S/ / 1 STREET STATE Z,p ABLE) OPERATOR PHONE GFACILITY F/'IY(IF FI7L ADDRESS(/OGN/L �OlF rT - OA568r/ cm PL� y CROSS STREET i I LOCAL AGENCY GENCY NAME S T- Ca. PtlS E/�� CONTACT PERSON / %,0-CY�='N PHONE . CQ/G rQ (tog) ZAV-o3� w M REGIONAL BOARD PHONE as m (U NAME QUANTITY LOST (GALLONS) a> KUNKNOWN Qm z (R) y ❑ UNKNOWN i DATE DISCOVERED DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS G� 0 / r r ❑ TANK TEST TANK REMOVAL ❑ OTHER a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) M M D o v r UNKNOWN ❑ REMOVE CONTENTS ISI CLOSE TANK& REMOVE ❑ REPAIR PIPING 'yQ'a' p E]REPAIR TANK CLOSE TANK & FILL IN PLACE E] CHANGE PROCEDURE HAS DISCHARGE BEEN STOPPED? v o ❑ YES ❑ NO IFYES. DATE ❑ REPLACE TANK ❑ OTHER M MI 01 ol Yl v SOURCE OF DISCHARGE CAUSE(S) a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL HO E:] PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER w w CHECKONEONLY O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS O ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ ❑ EXCAVATE& DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ENHANCED BIODEGRADATION (IT) ISPPROPRII SEE A QZ 00 ❑ CAP SITE (CO) ❑ EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (Gr) REPLACE SUPPLY (RS) r a ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) �2ESv�T - IL r.kov Z- ,�! SaiG AJ l�A ��l'r.4��i r^,Kl xFve7.T1fi� -/tom Or^T�.�¢rsi✓E T-,�' .t%4%'U!-°E >4/�t� EkT'cM/- of Cvci^TA/'-r�- NSC m (Esq o'14.