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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY : <br /> ❑ YES [j�w'NO REPORT BEEN FILED? ❑YES Q'NO HEREBY CERTIFY'.THAT IAMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORTDATE O CASE• THE AND SAFfY CODE M / M Z 1[J/ �j 1 V I V $DL F <br /> NAME OF INDIVIDUAL FLING REPORT PHONE I SIpNATuRE <br /> DATE <br /> blk- <br /> �u REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> 0 EfrLOCALAGENCY ❑ OTHER <br /> w <br /> � <br /> ADDRESS <br /> 445 5,4M Jol4auml 5-fz>4jE�-Tat,1 7— <br /> IM <br /> w BfaE ZIP <br /> NAME <br /> CONTACT PERSON PHONE <br /> *Dfft /ate W:T3 ❑ UNKNOWN ANDY LUvE (z ►)�6�/- a4o <br /> m a ADDRESS - -ro-� C� 9�ZDOj <br /> sTREEr cm WATE nP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 4 AI D YS /4t/'r AKTz�, ,ANoy i-o?_87� (74ei) 1f64-Q4fv7 <br /> ADDRESS <br /> Z�3v f STv�/croy.I S9N J044?L` t4ME <br /> g5ws <br /> cm co m P <br /> �+ CROSS STREET <br /> 51D LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w� SAN�,4gvuJ co. /IvBNL Glkl Sfi�v�FS E�}L� v /� (zoq)�dg-3� <br /> ZZ <br /> w REGIONALBOARD PHONE <br /> �, !�P, G/ o� GB <br /> ( ) <br /> m (D /�-1> NAME QUANTITY LOST(GALLONS) <br /> �w <br /> 'd5eUNKNOWN <br /> (2) Y VGf <br /> y <br /> ❑ UNKNOWN <br /> w DATE DISCOVERED HOWDISCOVERED ❑ NVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> C). I M ZD 1-1.1r r ❑ TAN(TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> IM M M D 0 Y Y <br /> �IQJOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> >Q HASDISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPWG ❑ CHANGE PROCEDURE <br /> O YES ❑ NO IFYES,DATE M M DI DI Yl Y ❑ OTHER <br /> i w SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANKLEAK ©UNKNOWN ❑ OVERFILL ❑ RUPTURNFAILURE ❑ SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION Ey UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKWGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHONLY <br /> z ECKNO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E] ENHANCED Bp DEGRADATION(IT) <br /> a 4 ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ED ❑ PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER ICE) ❑ NO ACTION REQUIRED INNA) ❑,, 7/REpTMENTAT HOOKUP(HU) - ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑.OTHER(OT) 5 SEGO-1// <br /> �aRTRf�k sr 4_4 R� E4v�kF� �v OeTEk,�Iet T k��Nn <br /> 'F�hrv� coYlTidtitlNA /arV REQv/ 87NE /d�i°PoPRI ATF /PF6/�G�9cm�� <br /> A6Rv-,r <br /> KBCOS(„/Bq <br />