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0 ! 01-3 u c � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCYSERVICE FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? 1HEREB CERTIFYTHAT HAVE DISTRIBUTED THIS INFORM ATI ACCORDING TO THE <br /> ❑ YES NO YES NO <br /> DIST UTION OWN 0 E NSTR TION HEFT ON THE e K PAGE OF THIS FORM <br /> REPORTDATE CASE& /) -f3 <br /> M 5M O DATE. <br /> N E OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> w REPRES G O OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> m LOCAL AGENCY 0 OTHER <br /> S <br /> ADDRESS <br /> STATE//////JJ <br /> 0• O Zo�q /�Ciiy <br /> rONTACTPERSON PHONE <br /> N UNKNOWN �iH6sGtTff �b5� •03/� <br /> 0, ADDRESS {wj/,�y/ ��J L// J <br /> STREET •.✓�v B O K b DRYS&6\ /J Z STATE 2 <br /> FACILITY NAME(IF APPLICABLE) OPERATORPHONE <br /> d 30 <br /> 1e <br /> id Es 1201367 <br /> ti <br /> ADDRESS <br /> f �D�/� (/ ///J� /^/^``T �,CC��/�( •//�/./�, 'J <br /> O L/ STREEr ♦ (y/\ / cm �Ll� DQDH{`/ U�/✓ IP (� <br /> y <br /> CROSS STREET I <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> zy <br /> w� d -� /N• M6 N� -IfAe fs (2 ) ?3Ysa <br /> w w RE//G��IONAL BOA // PHONE C M <br /> a s / 6 Y 4<. 30 6 ors 1A 53000 <br /> y (7) NAME QUANTITY LOST(GALLONS) <br /> /Za3i <br /> Ant �( UNKNOWN <br /> Q� <br /> w <br /> Uw <br /> 2 (2) <br /> m 0 UNKNOWN <br /> i <br /> DA <br /> TE DISCOVERED 9 HOW DISCOVERED Q INVENTORY CONTROL O UBSURFAC MONITORING NUISANCE CONDITIONS <br /> 6 -.1 { b TANK TEST TANK REMOVAL BOTHER G /N(J <br /> �u M N D Y <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> Q UNKNOWN REMOVE CONTENTS O CLOSE TANK B REMOVE ZEPAIR PIPING <br /> w MM D Y Y <br /> HAS DISCHARGE BEEN STOPPED? Lj REPAIR TANK 0 CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE ml MI D D r r REPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> n TANK LEAK ZUNKNOWN OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> wo 0 PIPING LEAK Q OTHER Q CORROSION UNKNOWN 0 OTHER <br /> yw6 CHECK ONE ONLY <br /> O ❑ UNDETERMINED dSOIL ONLY 11 GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� F-1 NOACTIONTAKEN F-1 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> ¢r F-] LEAK 13EINGGONFIRMED dPRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> 0 m ❑ REMEDIATION PLAN F-1 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E:] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F__j EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> Is�e.cawROEYusI <br /> CAP SITE(CO) <br /> E] EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> OO <br /> ~ ❑ CONTAINMENT BARRIER(CEI) NO ACTION REQUIRED INA) TREATMENT AT HOOKUP(HU) VENTSOIL(VS) <br /> ¢a <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> -5175: !09e AG671 1ee7d/e6Z �O d6-r:;oem1NE <br /> H IA"a% <br />