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qcV -��� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED? ❑YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DIM IBUTICNI SHOWN CNTHEINSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE CASE <br /> SIGNED k DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> p ofl V6k <br /> wREPRESE G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER ✓ //� �u 4, Ccs l�n S�` (/«C'S <br /> ¢ ADDRESS <br /> STREET <br /> CITY STATE 21P <br /> W NAMECONTACT PERSON PHONE <br /> J - <br /> Z �ClI) 5 �i /1G r�>� UNKNOWN /"!-Gi //7 <br /> a0.< ADDRESS <br /> W a �r O�.� cls-vcLy S 1v % , <br /> cr <br /> STREET <br /> CITY STATE 71P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> S ,�� u , ����, ��-��. — S /,z % (Zoe) <br /> < ADDRES <br /> C.) /0// N- /-jr 4;�cU� S <br /> w STREET CITY COUNTY zip <br /> y CROSS STREET L <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> N <br /> z W ( ) <br /> U <br /> w w REGIONAL BOARD PHONE <br /> a. <br /> J C7 <br /> U) (1) NAME QUANTITY LOST(GALLONS) <br /> W p / / _ <br /> Z /�O GC PG/ c G� S' �� NKNOWN <br /> y z (Z) <br /> m_ <br /> "' ❑ UNKNOWN 4 <br /> i <br /> DATEDISCOVEREDOI/SCOVERED �1 HOW DISCOVERED ❑ ENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w J v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE CK ALL THAT APPLY) <br /> a <br /> m Y) <br /> } UNKNOWN ❑REMOVE CONTENTS CLOSE TANK d REMOVE ❑REPAIR PIPING <br /> Lu <br /> ¢ M o o r r <br /> 0 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> C/) <br /> ❑ YES ❑ NO IF YES,DATE .I j o r Y ❑REPLACE TANK ❑OTHER <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> y v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> wnW CHECK ONE ONLY <br /> v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMRTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ <br /> =I F7LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (eEP @AM FCR OETMM <br /> E5 O <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 3 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Q< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> � S:>t� S Gr i"��(' Y�S�l�s .+'T fz.ti/G N2'/nCJ✓� l�cGC C Cc� C�D/t Tei n�ii.cL�lO'� <br /> z <br /> Sir' GSS�rSisiG� w�!/ �2C2fS�u� �j G��. .,� „Y �Z<L <br /> v E'�-,l�it: �-� CO lZ�tin/`•��/r✓'>` C(S f�P.-cam G,/i•F� '� oL /�� (s-�c.fr"y ���G,�,� .� <br /> J HSC osl&m <br />