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669 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE.ONLY <br /> 0 <br /> YES NO <br /> REPORT BEEN FILED 9 YES � NO 1 HEREBY.CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING T.Ci� � <br /> DISTRIBUTION SHOWN ON:THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM. ' <br /> REPORT DATE TYcA" <br /> E a <br /> VM 1 M 0�,3 SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN R <br /> co <br /> w REPRESENTING OWNER/OPERATOR a REGIONAL BOARD COMPANY OR AGENCY NAM <br /> pg LOCALAGENCY-.[:] OTHER <br /> ADDRESS ( Q�r✓h 2 /��A� <br /> 3v � 6 iKJ - W TREET �e- U h� r CITY �D d4 • � STATE c A- Zlp <br /> w NAMEn CONTACT PERSON PHONE <br /> (' <br /> 59 <br /> z� 00 ///�1"l, Q I Ca��I�a UNKNOWN ( L(J ) ��jJ O <br /> ac ADDRESS _�(I__ <br /> cn <br /> L ccS�oG �OY� CA- q-5 20 <br /> `.� •_ STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> roc roo <br /> c <br /> ADDRESS <br /> `/�^J <br /> J i 2- STRENET - CITYS�O�C�� COU ZIP <br /> LU <br /> N CROSS STREET. <br /> Y r �ryl0yl,-�- <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zc <br /> Lu <br /> W U <br /> w a B <br /> REGIONAL O D PHONE <br /> U) (t) NAME QUANTITY LOST(GALLONS) <br /> w> S ��+ <br /> a J o UNKNOWN <br /> m'> (z) <br /> Z rQ � e <br /> U) W C UNKNOWN <br /> zDATE DISCOVERED Y HOW DISCOVERED F-1INVENTORYCONTROL O SUBSURFACE MONITORING El (NUISANCE CON ITIONS <br /> MI MI DI D1 ©v� O TANK TEST TANK REMOVAL OTHER S'(• aSSPS <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) O <br /> g <br /> � UNKNOWN REMOVE CONTENTS;K CLOSE TANK&REMOVE a REPAIR PIPING <br /> M <br /> tr <br /> w M D D Y Y <br /> 0O HAS DISCHARGE BEEN STOPPED 7 �� �� E:]REPAIR TANK 0 CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> U <br /> 0 YES a NO IF YES,DATE REPLACE TANK OTHER <br /> 0 M MI D D Y Y I <br /> Ic- <br /> SOURCE OF DISCHARGE ��/ CAUSE(S) y <br /> D< F-] TANKLEAK I CI UNKNOWN a OVERFILL F-] RUPTUREIFAILURE a SPILL <br /> 0 v 0 PIPING LEAK � OTHER CORROSION UNKNOWN O OTHER <br /> Cw w CHECK ONE ONLY <br /> v WUNDETERMINED SOIL ONLY GROUNDWATER a DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w cn ® NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> O LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> U O REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE&DISPOSE(ED) a REMOVE FREE PRODUCT(FP) 0 ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK ECR DE TAI ) <br /> Z O CAP SITE(CD) a EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w� <br /> Q a a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) 0 OTHER(OT) <br /> U) /T 1- oi- "r-F -cl o N rt ,/1 So i C cy rq !.U`t- S <br /> C���Q C ul'� oL�Ct� �J ILS G(n G� CCor��n5 "�o V bonti rhLf <br /> a.s b e o C c L< ; b a. S no oj l s e. vice. S I� w as d- d t l s . <br /> p -r s y Les -- +e <br /> �V�/^✓Y)I� 'i' '„-f�,'�.� D� ->�� �-" i l�Q/m t �.Lt."� t Q� � S rQ 1111,E l ;sc 05("o) <br />