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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGE SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ VES , 1U—//NO REPORT BEEN FILED? YES ❑ NO HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT.EMPLOYEE AND THAT I HAVE: <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURS ANT TO SECTION 251807 OF <br /> REPORTOATE CASE# 101 TH kHF THA lCODE <br /> dM 3m D 9Y / Y N l R'Z, � "C..� Y<' /ti-U^_ I' _�✓ ,,,. f <br /> DATE' <br /> NAME OFINDIVIDUAL FILING REPO$j PHONE SIGNATUHE <br /> �, `a. e 4201h qbf-3Y3 y <br /> REPRESE G ❑ OWNERIOPERATOR ❑ REGIONAL BOARD (COMPANY OR AGENCY NAkW <br /> LOCAL AGENCY ❑ OTHER \am Az <br /> ADDyfiS$ <br /> 0 . aQ^� 9 �Sr c-r4oyu <br /> 9TREEf qry <br /> NAME y�/'^y/.., ,'A,. SATE 2W <br /> i i- sl 'K4 I,`�/7�, ❑ UNKNOWN CONTACT PERSON PHONE <br /> j \/2r r ��rrJ t�(J if f9i 37�3F <br /> S n ADD56 RESS _vs VaA. &e) ��, J c-e ✓ l- 'J L �O� Lis <br /> !/%, €T <br /> 4TRE Cm SPATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> J ,,� Ziv-p ra r r, C dib f3/-3 73 <br /> ADDRESS,�5C)�'f cJ`t � 95av <br /> cmc P <br /> �+ CROSS STREET <br /> i LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> C s — J5 14 <br /> U. r�ci�l6P-3�/3 <br /> M REGIONAL BOA <br /> a a C PHONE <br /> ( <br /> 6O (1) NAME QUANTITY LOST(GALLONS) <br /> FW x Cl< G�.-C.� <br /> 0 Q UNKNOWN <br /> m (2) Ij <br /> N <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED 9 HOWDISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONIT)RING ❑ ISA ECO ITIONS <br /> k' DM 3M o L v /Y ❑ TAW(TEST ❑ TANK REMOVAL f2l" N [ <br /> a DATE DISCHARGE BEGAN IST/,_ METHOD USED TO STOP DISCHARGE(CHECK ALL THA Y) <br /> M M o o v Y 2 'UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK LOSE TANK <br /> O <br /> HASDISC GESEENSTOPPED? ❑ REPAIR <br /> TANK <br /> ❑ REPAIR PIPING CHANGE PROCEDURE <br /> YES <br /> ❑ NO FYES,DATE O 9M ' OTHER <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREFAILURE ❑ SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> y n CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECKON NLY <br /> NO ACTION TAKEN ❑ PRELIM WARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING W PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT OFF) ❑ ENHANCED BD DEGRADATION(IT) <br /> 2PffercKranost,AAl <br /> wQ ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ¢� ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION RECUIRED(NA) ❑ TREATMENTAT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) F-1 OTHER(OT) <br /> t2 4c6t C.{u r, at �e <br /> /p�DDO q xa4, e 0�r yi rr �J x c 3 <br /> 8 <br /> xAcosl,VNq <br />