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9. 2 - u 3s 0 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES D REPORT BEEN FILED? FORLOC,I"AGI Il, EONLY <br /> ❑YES NO I HEREBY CERTIFYTHAT i HAVE DISTRIBUTEDTHIS INFORMAj10N ACCORDING TO THE <br /> REPORT DA DISTRIBJJJT. <br /> �j CASEr fiTHUC➢ON SHEET ON BAC(PPAGGEE OF THIS FDRM <br /> NEINDIVIDUALOF INDIVIDUAL FILING REPORT <br /> s/ C / NED <br /> m L/T'�l ��I�VLN PHONE SI RE DATE <br /> REPRESENTING` ❑ OWNER/OPERATOR ) D� <br /> ❑ REGIONAL BOARD COMPANY ORq EN AME <br /> S ALAGENCY ❑ OTHER <br /> w <br /> � ADDRESS <br /> A/y7 �`SUAI�v�C/�T �GLK%Oti/ . <br /> W NAME cm <br /> m CONTACT PERSON SATE <br /> y Z ziv <br /> y as ADDRESS ❑ UNKNOWN PHONE <br /> FACILITY NAME <br /> /(IF <br /> FAAPP LICABLE) STREET /1�-/ ✓ /"'� G� Cy,��.7� <br /> TOG`/ /�(�' OPERATOR sT^TE / !/iv <br /> o �d (J''/ �j� PHONE <br /> /zL <br /> yCROS/SSS STREET srREEr CITY �• Si �vV/V�r� Q�zy <br /> "V l�� COURTr zF <br /> 0 LOCALAGENCY N AGENCY NAME <br /> w f n CONTACT PERSON <br /> w REGIONAL BOARD <br /> PHONE <br /> n) <br /> i w NAME <br /> F o / its✓G/� G�v/� QUANTITY LOST(GALLONS) <br /> > �V <br /> y (2) KNOWN /1 <br /> DATE DISCO ERED ❑ UNKNOWN <br /> w HOW DISCOVEflEDED 1 TORY CONTROL ❑ SUBSURFACE MONITORING <br /> �+ OMI M O ) p r E] TANK TEST TANK REMOVAL ❑ NUISANCE CONDITIONS <br /> DATE DI HARGE BEGAN ❑ OTHER <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) 1W <br /> 8 w M M o r UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE l 1, <br /> HAS DISCHARGE BEEN STOPPED A ❑REPAIR PIPING _' 1 <br /> w ❑REPAIR TANK <br /> ❑ VES ❑ NO IF YES,DATE F-1CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> ❑ p r r ❑REPLACE TANK ❑OTHER <br /> SOURCE Of DISCHARGE M MI <br /> CAUSES) <br /> Q ❑ TANK LEAK UNKNOWN <br /> y ti [I OVERFILL <br /> El A TUREIFAILURE <br /> E] PIPING LEAK ❑ OTHER E] SPILL <br /> ❑ CORROSION UNKNOWN <br /> a CHECK ONE ONLY ❑ OTHER <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWA7Efl ❑ <br /> CHECKO NLY DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> i <br /> w NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POLLUTION CHARACTERIZATION <br /> Q ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ POST CLEANUP MONITORING IN PROGRESS <br /> CHECK APPROPRIATE ACTION(S) ❑ CLEANUP UNDERWAY <br /> a (' "77 <br /> w —1 ❑ EXCAVATED (ED) ❑ REMOVE FREE PRODUCT(FP) <br /> )o E:3 CAP SITE(CD) ❑ ENHANCED BIO DEGRADATION(IT)r <br /> EXCAVATE TREAT(ET) ❑ PUMP&TREAT GROUNDWATERG <br /> c¢ � CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ( T)❑ REPLACE SUPPLY(RS) <br /> VACUUM EXTRACT(VE) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ OTHER(OT) <br /> /PE'vr6Hi oL Sr1/L /�FfiG'/sls �z°�C, F/L/6vi9 <br /> � �i(lTi�<rc/�kricaK.✓. �-riiA�F,� ,��7-,E iA5�,E�� /e L .i.�le9/�..•¢TE S'OiC <br /> Aiy/, Ti`>vl <br /> H9c 0(8q0) <br />