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00 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMEly"ERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY <br /> �-TR�NO REPORT BEEN FILED 9 TtlS ❑ NO I HEFEBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ VES LJ VE DISTRIBUTION SHOWN ONTHE INSTRUCTION SHEETONTHE BACK PAGE OFTHIS FORM <br /> REPORTDATE // {'� CASES <br /> M 6M1 (0 V A VTy y 'SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 62kot 0Z— (moi) Y6834Yo <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> CC '�qq <br /> p LOCALAGENCV ❑ OTHER SSL P <br /> ADDRESS <br /> 3 v q L ) e d ei- /lve, &40c,lcfvvl G4 qs;�_v/ <br /> STREET <br /> cm STATE ZIP <br /> j NAM/E, /' n CONTACT PERSON PHONE <br /> i¢ (. (V. Ot _C�O !' [L ❑UNKNOWN f7 Pi �1/Y//-n ( abs) 9Ylo -aSt// <br /> as ADDRESS �'/ �-4 <br /> , G • T <br /> O t /-/J LCC` Ove_ STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> _ C�/7 rV. ot,f/ 1'lc c TI,c. ✓ve kr r-1 r-T-, ( 200 /c: -a-Sc// <br /> 0 <br /> < ADDRESS G(SZI I <br /> o , / �✓cloGt;7D 51Vr Envy, 5� co , <br /> Joel cJ <br /> -I STREET CITY COUNTY IIP <br /> W <br /> � CROSS STREET ' <br /> to"t t- to c <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w 5 SG P/ts / G z l 2dt ) Ylo(p y L <br /> w Z. REGIONAL BOARD PHONE <br /> f <br /> rn (T) NAME QUANTITY LOST(GALLONS) <br /> '+'o rr NKNOWN <br /> ¢ ti1T9 G <br /> m° (Z) <br /> D z ❑ UNKNOWN <br /> i DATEI DISCOVERED / HOW DISCOVERED E4] IN NTORY CONTROL ❑ SUBSURFACE MONITORING E::] NUISANCE CONDITIONS O <br /> r <br /> YJ O Y ❑ TANK TEST TANK REMOVAL ❑ OTHER S21S' .•- <br /> METHOD USED TO STOP <br /> DATE DISCHARGE BEGAN UNKNOWN ❑REMOVE CONTENTS DISCHARGE <br /> CLAPPLY) <br /> OSE TANK&REMOVE ❑REPAIR PIPING <br /> Tc mE <br /> p HAS DISCHARGE BEEN STOPPED? Y ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE uI uI o o y y ❑REPLACE TANK ❑OTHER <br /> Ia SOURCE OF DISCHARGE CAUSES) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE[FAILURE E::] SPILL <br /> 0w ❑ PIPING LEAK ❑ OTHER ❑ CORROSION EE-UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> EeUNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ F-1 NOACTIONTAKEN E?"PflELIMINARV SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O w ❑ 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 /> Iran <br /> 8 F—] CAP SITE(CD) <br /> ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP E TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) <br /> E] VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) <br /> ❑ OTHER(OT) <br /> lsi t/cssess c�("/ be recess /may ,4D We 4e, Ri a P'C'4 'o 4 <br /> CX�C 07 /G'{'LvR IIy R, wLf v2r'fl Cq.ttY . <br /> f / <br /> 0 <br /> U <br /> HSC M(IM)% <br />